Provider Demographics
NPI:1568773968
Name:CALLAS, ZACHARY M
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:M
Last Name:CALLAS
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 1:535 S CURSON AVE # 49MB
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5252
Mailing Address - Country:US
Mailing Address - Phone:530-913-8031
Mailing Address - Fax:
Practice Address - Street 1:535 S CURSON AVE # 49MB
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5252
Practice Address - Country:US
Practice Address - Phone:530-913-8031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children