1386717007 NPI number — KATHLEEN MARIE KALLMAN LPC, BCPC

Table of content: KATHLEEN MARIE KALLMAN LPC, BCPC (NPI 1386717007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386717007 NPI number — KATHLEEN MARIE KALLMAN LPC, BCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALLMAN
Provider First Name:
KATHLEEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, BCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KALLMAN
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, BCPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1386717007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
591 SYCAMORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65401-4733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-433-0315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13160 COUNTY RD 3610
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. JAMES
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-265-3251
Provider Business Practice Location Address Fax Number:
573-265-0156
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2005009300 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 497293605 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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