Provider Demographics
NPI:1407953037
Name:CALLAN, PAUL DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL DOUGLAS
Middle Name:
Last Name:CALLAN
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 1:1361 N LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8867
Mailing Address - Country:US
Mailing Address - Phone:810-629-6549
Mailing Address - Fax:810-629-0614
Practice Address - Street 1:1361 N LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-8867
Practice Address - Country:US
Practice Address - Phone:810-629-6549
Practice Address - Fax:810-629-0614
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM58660Medicare ID - Type Unspecified