Provider Demographics
NPI:1811036908
Name:POULOS, CALLIE JORDAN (SLPL)
Entity Type:Individual
Prefix:MS
First Name:CALLIE
Middle Name:JORDAN
Last Name:POULOS
Suffix:
Gender:F
Credentials:SLPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 W OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3618
Mailing Address - Country:US
Mailing Address - Phone:602-707-8624
Mailing Address - Fax:602-707-2040
Practice Address - Street 1:1526 W MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2616
Practice Address - Country:US
Practice Address - Phone:602-707-8624
Practice Address - Fax:602-707-2040
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5130235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist