Provider Demographics
NPI:1235481235
Name:KALLIS, NATHALY (MA, LMHC, CRC)
Entity Type:Individual
Prefix:
First Name:NATHALY
Middle Name:
Last Name:KALLIS
Suffix:
Gender:F
Credentials:MA, LMHC, CRC
Other - Prefix:
Other - First Name:NATHALY
Other - Middle Name:
Other - Last Name:MINIELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:970 LAKE CARILLON DR
Mailing Address - Street 2:SUITE 345
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1129
Mailing Address - Country:US
Mailing Address - Phone:727-565-3077
Mailing Address - Fax:
Practice Address - Street 1:970 LAKE CARILLON DR
Practice Address - Street 2:SUITE 345
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1129
Practice Address - Country:US
Practice Address - Phone:727-565-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health