Provider Demographics
NPI:1649497330
Name:KALT, BETHANN (PHD)
Entity type:Individual
Prefix:DR
First Name:BETHANN
Middle Name:
Last Name:KALT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32255 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1566
Mailing Address - Country:US
Mailing Address - Phone:248-626-5600
Mailing Address - Fax:
Practice Address - Street 1:32255 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 250
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1566
Practice Address - Country:US
Practice Address - Phone:248-626-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008581103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11279881OtherCAQH
MI0N56370Medicare ID - Type Unspecified