Provider Demographics
NPI:1700441888
Name:NAUERTZ, KALLIE
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:NAUERTZ
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 1:1004 BOMBAY LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5820
Practice Address - Country:US
Practice Address - Phone:678-288-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical