Provider Demographics
NPI:1407174048
Name:STOCKMAN, CALLIE LYNN (COTA, PM)
Entity Type:Individual
Prefix:MS
First Name:CALLIE
Middle Name:LYNN
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:COTA, PM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-4937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 HICKORY ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-4937
Practice Address - Country:US
Practice Address - Phone:260-484-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001155A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant