Provider Demographics
NPI:1275075889
Name:CALLAHAN, THOMAS JOSEPH IV (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:CALLAHAN
Suffix:IV
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:10135 GATE PKWY N
Mailing Address - Street 2:APT 1116
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8274
Mailing Address - Country:US
Mailing Address - Phone:352-213-8851
Mailing Address - Fax:
Practice Address - Street 1:6248 103RD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7733
Practice Address - Country:US
Practice Address - Phone:904-573-0046
Practice Address - Fax:904-573-0772
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL27255225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant