MEDICARE: JOYCE MARIE KALLENBERGER

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	225X00000X	Occupational Therapist	2004011316	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2004011316	OTHER	MO	DIVISION OF PROFESSIONAL REGISTRATION

General Provider Information

NPI Number	:	1669030755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOYCE MARIE KALLENBERGER

Provider Business Mailing Address
First Line	:	8200 NW WEATHERBY DR
Second Line	:
City	:	WEATHERBY LAKE
State	:	MO
Zip	:	64152-1596
Country	:	US
Telephone Number	:	816-694-5494
Fax Number	:

Provider Business Practice Location Address
First Line	:	8200 NW WEATHERBY DR
Second Line	:
City	:	WEATHERBY LAKE
State	:	MO
Zip	:	64152-1596
Country	:	US
Telephone Number	:	816-694-5494
Fax Number	:

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

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	06/03/2019

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