Provider Demographics
NPI:1699769604
Name:KLOSTERMANN, DWAIN RAY (OT)
Entity type:Individual
Prefix:
First Name:DWAIN
Middle Name:RAY
Last Name:KLOSTERMANN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-4603
Mailing Address - Country:US
Mailing Address - Phone:325-793-3400
Mailing Address - Fax:325-793-3534
Practice Address - Street 1:4601 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4603
Practice Address - Country:US
Practice Address - Phone:325-793-3400
Practice Address - Fax:325-793-3534
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100807225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A008OtherTRICARE
8T0879OtherBCBS
TX8A8359Medicare ID - Type Unspecified