Provider Demographics
NPI:1952065963
Name:DEWESE, CALLIE ERICSON
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:ERICSON
Last Name:DEWESE
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 1:8256 CHATHAM OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-9606
Mailing Address - Country:US
Mailing Address - Phone:774-275-1291
Mailing Address - Fax:
Practice Address - Street 1:1136 SAM NEWELL RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5063
Practice Address - Country:US
Practice Address - Phone:704-900-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health