Provider Demographics
NPI:1306032982
Name:FRYE, CALLISTA (PSYD)
Entity Type:Individual
Prefix:
First Name:CALLISTA
Middle Name:
Last Name:FRYE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 LAKE EARL DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95532-0001
Mailing Address - Country:US
Mailing Address - Phone:805-704-7617
Mailing Address - Fax:
Practice Address - Street 1:5905 LAKE EARL DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95532-5353
Practice Address - Country:US
Practice Address - Phone:707-465-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LP 2099103TC0700X
CAB7715996390200000X
CAPSY29061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program