Provider Demographics
NPI:1376600502
Name:MCCALLUM, KENNETH ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:MCCALLUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159316
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96830-1005
Mailing Address - Country:US
Mailing Address - Phone:808-590-1478
Mailing Address - Fax:808-922-5385
Practice Address - Street 1:1188 BISHOP ST
Practice Address - Street 2:SUITE 3512
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-3301
Practice Address - Country:US
Practice Address - Phone:808-590-1478
Practice Address - Fax:808-922-5385
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY - 610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH102203Medicare PIN