Provider Demographics
NPI:1427599752
Name:KALVELAGE-ROTH, BECKY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:
Last Name:KALVELAGE-ROTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N MEADOW ST
Mailing Address - Street 2:P.O. BOX 295
Mailing Address - City:GRANT PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60940-7077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 E NORTH ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1185
Practice Address - Country:US
Practice Address - Phone:815-933-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist