Provider Demographics
NPI:1679872394
Name:KLEIN-SOUTH, ELLEN MARGO (MS)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MARGO
Last Name:KLEIN-SOUTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3881 NE SUGARHILL AVE
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3731
Mailing Address - Country:US
Mailing Address - Phone:772-334-4035
Mailing Address - Fax:772-334-4036
Practice Address - Street 1:3881 NE SUGARHILL AVE
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3731
Practice Address - Country:US
Practice Address - Phone:772-334-4035
Practice Address - Fax:772-334-4036
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS0000535103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ127BOtherBLUE CROSS/ BLUE SHIELD INSURANCE