Provider Demographics
NPI:1407113145
Name:CALLAN, NICOLE TERESA (MA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:TERESA
Last Name:CALLAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MCGLYNN PL
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2305
Mailing Address - Country:US
Mailing Address - Phone:516-569-3083
Mailing Address - Fax:516-374-1185
Practice Address - Street 1:124 MCGLYNN PL
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2305
Practice Address - Country:US
Practice Address - Phone:516-569-3083
Practice Address - Fax:516-374-1185
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY445404101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist