Provider Demographics
NPI:1114628542
Name:MCCALLISTER, STU
Entity Type:Individual
Prefix:
First Name:STU
Middle Name:
Last Name:MCCALLISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 GIDDINGS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2223
Mailing Address - Country:US
Mailing Address - Phone:616-826-7876
Mailing Address - Fax:
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-481-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker