Provider Demographics
NPI:1851068993
Name:MCCALLA, MARK-ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK-ANTHONY
Middle Name:
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 1:4431 NW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3673
Mailing Address - Country:US
Mailing Address - Phone:754-265-1253
Mailing Address - Fax:
Practice Address - Street 1:4431 NW 20TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-3673
Practice Address - Country:US
Practice Address - Phone:754-265-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-171293106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty