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General NPI Number Information
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NPI Number | 1861734600
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Entity Type | Individual
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Provider Name | EDWARD J KLUTCHARCH PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 03/19/2013
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Last Update Date | 07/19/2022
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Provider Practice Location Address
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Address Line | 6502 JOLIET RD
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City | COUNTRYSIDE
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State | IL
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Zip | 60525-4682
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Country | US
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Telephone | 708-608-1167
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Fax |
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Provider Business Mailing Address
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Address Line | 8624 WHEELER DR
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City | ORLAND PARK
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State | IL
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Zip | 60462-4704
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Country | US
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Telephone | 708-608-1167
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008553
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License Number State | IL
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