Provider Demographics
NPI:1639389174
Name:KALISCH, STEVEN MARK (PHD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MARK
Last Name:KALISCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 GATEWAY BLVD N
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9658
Mailing Address - Country:US
Mailing Address - Phone:219-921-1444
Mailing Address - Fax:219-921-5303
Practice Address - Street 1:601 GATEWAY BLVD N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9658
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-921-5303
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004920103TC0700X
IN20040719A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN473320BBBMedicare PIN