Provider Demographics
NPI:1154647170
Name:CALLOWAY, LEI PORTUGAL
Entity Type:Individual
Prefix:
First Name:LEI
Middle Name:PORTUGAL
Last Name:CALLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEI
Other - Middle Name:
Other - Last Name:PORTUGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 W CIVIC CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4052
Mailing Address - Country:US
Mailing Address - Phone:714-795-3444
Mailing Address - Fax:
Practice Address - Street 1:615 W CIVIC CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4052
Practice Address - Country:US
Practice Address - Phone:714-795-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CATQGHCEAMIDJRPKSN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner