Provider Demographics
NPI:1902644925
Name:KLEIST, SAMUEL JOHN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
Last Name:KLEIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3553 ATLANTIC AVE # 168
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-5606
Mailing Address - Country:US
Mailing Address - Phone:901-235-3449
Mailing Address - Fax:
Practice Address - Street 1:3553 ATLANTIC AVE # 168
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-5606
Practice Address - Country:US
Practice Address - Phone:901-235-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1235081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical