Provider Demographics
NPI:1225727159
Name:CALLAHAN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CALLAHAN
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 1:58 N SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 N BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9734
Practice Address - Country:US
Practice Address - Phone:567-230-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.183627101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)