Provider Demographics
NPI:1558864694
Name:MCCALLA, ANDRE LLOYD
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:LLOYD
Last Name:MCCALLA
Suffix:
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 1:5060 SW 64TH AVE APT 213
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-5228
Mailing Address - Country:US
Mailing Address - Phone:954-587-2155
Mailing Address - Fax:
Practice Address - Street 1:11441 INTERCHANGE CIR S
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-6009
Practice Address - Country:US
Practice Address - Phone:305-573-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty