Provider Demographics
NPI:1235659632
Name:MCCALL, KERI ELLEN
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:ELLEN
Last Name:MCCALL
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 1:1514 BOONE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3708
Mailing Address - Country:US
Mailing Address - Phone:260-217-5902
Mailing Address - Fax:260-202-5202
Practice Address - Street 1:3711 RUPP DR STE 208
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4523
Practice Address - Country:US
Practice Address - Phone:260-217-5902
Practice Address - Fax:260-202-5202
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003263A101YM0800X
IN88000135A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300065057Medicaid