Provider Demographics
NPI:1386022937
Name:ZELLER, KALYN (LCSW)
Entity type:Individual
Prefix:
First Name:KALYN
Middle Name:
Last Name:ZELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 BROADWAY ST # C
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2973
Practice Address - Country:US
Practice Address - Phone:314-627-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2024-05-03
Deactivation Date:2021-02-22
Deactivation Code:
Reactivation Date:2024-05-03
Provider Licenses
StateLicense IDTaxonomies
MO2011028236104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker