Provider Demographics
NPI:1417490681
Name:CALDERON, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CALDERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14007 S BELL RD STE 183
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8463
Mailing Address - Country:US
Mailing Address - Phone:708-553-0602
Mailing Address - Fax:
Practice Address - Street 1:14007 S BELL RD STE 183
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491
Practice Address - Country:US
Practice Address - Phone:708-553-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012283101YM0800X
IL178012283101YP2500X
IL180.012970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417490681OtherNPI 1 NUMBER