Basic Information
| Provider Information | |||||||||
| NPI: | 1043371768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALCH | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FELTON | ||||||||
| OtherFirstName: | ROXANNE | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6360 TECHSTER BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2721 DEL PRADO BLVD S STE 200 | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396739034 | ||||||||
| FaxNumber: | 2396739102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 86000172A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 33005112A | IN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 34006093A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW16346 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000392863 | 01 | IN | ANTHEM | OTHER | 600018-064 | 01 | IN | MAGELLAN | OTHER | 200479690 | 01 | IN | MEDICAID SED WAIVER | OTHER |