Provider Demographics
NPI:1629017868
Name:KALLIS, JONATHAN A (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:KALLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-837-8767
Mailing Address - Fax:760-837-8806
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-837-8767
Practice Address - Fax:760-837-8806
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0009706104100000X
CA820791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8200117300Medicaid
OHKASW27431Medicare PIN
KY8200117300Medicaid