Provider Demographics
NPI:1902333842
Name:KLOTH, RACHEL LYNN
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LYNN
Last Name:KLOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60963-1026
Mailing Address - Country:US
Mailing Address - Phone:217-512-3149
Mailing Address - Fax:
Practice Address - Street 1:1630 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:TILTON
Practice Address - State:IL
Practice Address - Zip Code:61833-8109
Practice Address - Country:US
Practice Address - Phone:217-443-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IL1-19-39509103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst