Provider Demographics
NPI:1871017004
Name:CALLIS, ISABELLA GRACE
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:GRACE
Last Name:CALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 S HIGGINS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4155
Mailing Address - Country:US
Mailing Address - Phone:605-838-5063
Mailing Address - Fax:
Practice Address - Street 1:32 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0003
Practice Address - Country:US
Practice Address - Phone:406-243-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2017-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTATR-LAT-LIC-15572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer