Provider Demographics
NPI:1215200274
Name:CALLIS, KIERSTEN
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:CALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 EL PORTAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3305
Mailing Address - Country:US
Mailing Address - Phone:510-706-2247
Mailing Address - Fax:
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-706-2247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health