Provider Demographics
NPI:1992873384
Name:KALLEN, BONNIE S (PSY D)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:S
Last Name:KALLEN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE TIFFANY POINT
Mailing Address - Street 2:STE. #111
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108
Mailing Address - Country:US
Mailing Address - Phone:630-980-1400
Mailing Address - Fax:630-980-1441
Practice Address - Street 1:1 TIFFANY PT
Practice Address - Street 2:STE. #111
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2936
Practice Address - Country:US
Practice Address - Phone:630-980-1400
Practice Address - Fax:630-980-1441
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL971420Medicare ID - Type UnspecifiedMCARE PROVIDER