1811252554 NPI number — MELINDA K CALLICOAT LPC, LAMFT

Table of content: MELINDA K CALLICOAT LPC, LAMFT (NPI 1811252554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811252554 NPI number — MELINDA K CALLICOAT LPC, LAMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLICOAT
Provider First Name:
MELINDA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, LAMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREENBANK
Provider Other First Name:
MELINDA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811252554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
STE. 735
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85282-5691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-804-0326
Provider Business Mailing Address Fax Number:
480-804-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 S MCCLINTOCK DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282-2692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-804-0326
Provider Business Practice Location Address Fax Number:
480-804-0083
Provider Enumeration Date:
07/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  LAMFT-10349 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-14161 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 816306 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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