Basic Information
Provider Information | |||||||||
NPI: | 1326606369 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KALKASKA COUNSELING SERVICES, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAUREN BERTHELOT, LMSW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2257 | ||||||||
Address2: |   | ||||||||
City: | CHESTERTON | ||||||||
State: | IN | ||||||||
PostalCode: | 463040357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199268320 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 880 MUNSON AVE STE G | ||||||||
Address2: |   | ||||||||
City: | TRAVERSE CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 496863661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2319440384 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2019 | ||||||||
LastUpdateDate: | 10/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERTHELOT | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: | LAUREN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2319440384 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMSW | ||||||||
NPICertificationDate: | 10/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.