Provider Demographics
NPI:1003912379
Name:CALLIS, MARY MAZOR (RPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAZOR
Last Name:CALLIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:450 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2933
Practice Address - Country:US
Practice Address - Phone:203-453-0459
Practice Address - Fax:203-466-8527
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003921225100000X
CT3921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004128379Medicaid
CT080003921CT07OtherANTHEM BCBS