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: |   | ||||||||
OtherNameSuffix: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 |