Provider Demographics
NPI:1609249036
Name:KALLAS, MARENA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARENA
Middle Name:
Last Name:KALLAS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NOYES ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3854
Mailing Address - Country:US
Mailing Address - Phone:315-738-4023
Mailing Address - Fax:315-738-4403
Practice Address - Street 1:1400 NOYES ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3854
Practice Address - Country:US
Practice Address - Phone:315-738-4023
Practice Address - Fax:315-738-4403
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR057062171M00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator