Provider Demographics
NPI:1003061045
Name:CALLAHAN, JOHN B (BSW, MPA, CCM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:BSW, MPA, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-0540
Mailing Address - Country:US
Mailing Address - Phone:910-707-3821
Mailing Address - Fax:
Practice Address - Street 1:100 EIGHTH ST N
Practice Address - Street 2:
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428
Practice Address - Country:US
Practice Address - Phone:910-707-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101Y00000X, 171M00000X, 171W00000X, 172V00000X
4236690171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
4236690OtherCOMMISSION FOR CASE MANAGER CERTIFICATION