Provider Demographics
NPI:1063513513
Name:KALT, KELLY ANN (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:KALT
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 ELAINE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2458
Mailing Address - Country:US
Mailing Address - Phone:815-229-7102
Mailing Address - Fax:815-229-7108
Practice Address - Street 1:5702 ELAINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2458
Practice Address - Country:US
Practice Address - Phone:815-229-7102
Practice Address - Fax:815-229-7108
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0107051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158705OtherCOMPSYCH
506515OtherVALUEOPTIONS
7233792OtherAETNA
IL1715OtherMEDICARE PTAN
0010132116OtherBC/BS ID
IL830010000OtherMAGELLAN
IL830010000OtherMAGELLAN