Provider Demographics
NPI:1033759220
Name:NULL, CALLIE MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:MICHELLE
Last Name:NULL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 LOUISIANA ST APT 2J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104
Mailing Address - Country:US
Mailing Address - Phone:619-734-5282
Mailing Address - Fax:
Practice Address - Street 1:5060 SHOREHAM PL STE 330
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5976
Practice Address - Country:US
Practice Address - Phone:844-747-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78957225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty