MEDICARE: KRISTIN KLACIK MA LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15342	TX

General Provider Information

NPI Number	:	1891612412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN KLACIK MA LCDC

Provider Business Mailing Address
First Line	:	5419B S SCOTT PLZ
Second Line	:
City	:	FORT DIX
State	:	NJ
Zip	:	08640-2801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5419B S SCOTT PLZ
Second Line	:
City	:	FORT DIX
State	:	NJ
Zip	:	08640-2801
Country	:	US
Telephone Number	:	732-675-4818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2026
Last Update Date	:	07/03/2026

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