Provider Demographics
NPI:1831252345
Name:PANTALE, KERI A (LMSW)
Entity type:Individual
Prefix:MRS
First Name:KERI
Middle Name:A
Last Name:PANTALE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:KERI
Other - Middle Name:A
Other - Last Name:GOLDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:960 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9339
Mailing Address - Country:US
Mailing Address - Phone:269-445-2451
Mailing Address - Fax:269-445-3836
Practice Address - Street 1:960 E STATE ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9339
Practice Address - Country:US
Practice Address - Phone:269-445-2451
Practice Address - Fax:269-445-3836
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010868261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774349006Medicaid
MI0A46077Medicare ID - Type Unspecified