Provider Demographics
NPI:1376252536
Name:CALLAHAN, IMMANUEL LEWIS
Entity Type:Individual
Prefix:
First Name:IMMANUEL
Middle Name:LEWIS
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-2743
Mailing Address - Country:US
Mailing Address - Phone:216-532-9955
Mailing Address - Fax:
Practice Address - Street 1:3271 W 115TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-2743
Practice Address - Country:US
Practice Address - Phone:216-532-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUQ962169103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities