Provider Demographics
NPI:1114796562
Name:CALLAHAN, TRACY ALAN (CDCA)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:ALAN
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3577 LUDGATE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5007
Mailing Address - Country:US
Mailing Address - Phone:216-280-3862
Mailing Address - Fax:
Practice Address - Street 1:2450 FAIRMOUNT BLVD # M104
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44106-3100
Practice Address - Country:US
Practice Address - Phone:216-280-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH186881101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)