Provider Demographics
NPI:1922554310
Name:O'CALLAGHAN, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:O'CALLAGHAN
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:PO BOX 721597
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92172-1597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12640 SABRE SPRINGS PKWY
Practice Address - Street 2:111
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4113
Practice Address - Country:US
Practice Address - Phone:203-561-4934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22824235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist