Provider Demographics
NPI:1669030755
Name:KALLENBERGER, JOYCE MARIE
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:MARIE
Last Name:KALLENBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 NW WEATHERBY DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERBY LAKE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-1596
Mailing Address - Country:US
Mailing Address - Phone:816-694-5494
Mailing Address - Fax:
Practice Address - Street 1:8200 NW WEATHERBY DR
Practice Address - Street 2:
Practice Address - City:WEATHERBY LAKE
Practice Address - State:MO
Practice Address - Zip Code:64152-1596
Practice Address - Country:US
Practice Address - Phone:816-694-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011316225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004011316OtherDIVISION OF PROFESSIONAL REGISTRATION