Basic Information
Provider Information | |||||||||
NPI: | 1295702827 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLEICH | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7545 46TH STREET WAY N | ||||||||
Address2: |   | ||||||||
City: | OAKDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 551282219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517791074 | ||||||||
FaxNumber: | 6516463959 | ||||||||
Practice Location | |||||||||
Address1: | 2265 COMO AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551081737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6516468985 | ||||||||
FaxNumber: | 6516463959 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 13885 | MN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 985341029862 | 01 | MN | PREFERRED ONE | OTHER | 035T0KL | 01 | MN | BCBS | OTHER |