MEDICARE: MISS MICHELLE KALLAS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW7748	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538285085	OTHER	FL	NONE

General Provider Information

NPI Number	:	1538285085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MICHELLE KALLAS LCSW

Provider Business Mailing Address
First Line	:	503 SUNPORT LN
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7874
Country	:	US
Telephone Number	:	888-632-3862
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 SUNPORT LN
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7874
Country	:	US
Telephone Number	:	888-632-3862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	05/13/2019

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