Provider Demographics
NPI:1124189642
Name:CALLAGHAN, PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:CALLAGHAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST
Mailing Address - Street 2:STE F
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7943
Mailing Address - Country:US
Mailing Address - Phone:231-935-8900
Mailing Address - Fax:231-935-8901
Practice Address - Street 1:3537 W FRONT ST
Practice Address - Street 2:STE F
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7943
Practice Address - Country:US
Practice Address - Phone:231-935-8900
Practice Address - Fax:231-935-8901
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007528103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680B84515OtherBLUE CROSS BLUE SHIELD
MI0M07450Medicare UPIN