Provider Demographics
NPI:1083988414
Name:CALLEN, MARY ANN S (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:S
Last Name:CALLEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5490 THE PEAKS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1104
Mailing Address - Country:US
Mailing Address - Phone:610-547-0347
Mailing Address - Fax:
Practice Address - Street 1:3959 ELECTRIC RD STE 465
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4559
Practice Address - Country:US
Practice Address - Phone:540-632-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY511103T00000X
VA0810007635103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical