Provider Demographics
NPI:1417421363
Name:NETTLES, CALLIE JENNIFER (LMHC)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:JENNIFER
Last Name:NETTLES
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 W COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1203
Mailing Address - Country:US
Mailing Address - Phone:813-644-9659
Mailing Address - Fax:
Practice Address - Street 1:300 S HYDE PARK AVE STE 120
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-4117
Practice Address - Country:US
Practice Address - Phone:813-644-9659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14218101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health