1649701061 NPI number — ERICA JEAN CALLAHAN L.M.S.W.

Table of content: ERICA JEAN CALLAHAN L.M.S.W. (NPI 1649701061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649701061 NPI number — ERICA JEAN CALLAHAN L.M.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAHAN
Provider First Name:
ERICA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.M.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649701061
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 WEST CHESTNUT STREET
Provider Second Line Business Mailing Address:
SOUTH BAY COMMUNITY SERVICES,
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-578-1300
Provider Business Mailing Address Fax Number:
860-951-7729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
237 HAMILTON ST. SUITE 205
Provider Second Line Business Practice Location Address:
SOUTH BAY EARLY CHILDHOOD,
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-578-1300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2017

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 4743 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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