Provider Demographics
NPI:1114500840
Name:STALLTER, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:STALLTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 W WRIGHTWOOD AVE APT 607
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2963
Mailing Address - Country:US
Mailing Address - Phone:630-328-9674
Mailing Address - Fax:
Practice Address - Street 1:443 W WRIGHTWOOD AVE APT 607
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2963
Practice Address - Country:US
Practice Address - Phone:630-328-9674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0230111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical