MEDICARE: HEATHER KALLMAN PSYD

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	103TC0700X	Clinical Psychologist	071.010519	IL

General Provider Information

NPI Number	:	1407374275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER KALLMAN PSYD

Provider Business Mailing Address
First Line	:	4043 N RAVENSWOOD AVE STE 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5683
Country	:	US
Telephone Number	:	630-708-0869
Fax Number	:

Provider Business Practice Location Address
First Line	:	4043 N RAVENSWOOD AVE STE 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5683
Country	:	US
Telephone Number	:	630-708-0869
Fax Number	:

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

Provider Enumeration Date	:	08/31/2017
Last Update Date	:	07/05/2021

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