Provider Demographics
NPI:1437612116
Name:CALLAHAN, BURTON E III
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:E
Last Name:CALLAHAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNDERS PLZ STE 1802
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-8301
Mailing Address - Country:US
Mailing Address - Phone:860-569-5900
Mailing Address - Fax:
Practice Address - Street 1:500 BLUE HILLS AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1500
Practice Address - Country:US
Practice Address - Phone:860-569-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002922101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional