Provider Demographics
NPI:1821634759
Name:KALETA, BERNADETTE MARIA
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:MARIA
Last Name:KALETA
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 1:3321 N PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2916
Mailing Address - Country:US
Mailing Address - Phone:847-630-9024
Mailing Address - Fax:
Practice Address - Street 1:2211B LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1265
Practice Address - Country:US
Practice Address - Phone:847-607-1374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.01578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty