Provider Demographics
NPI:1255431938
Name:GRAY BOBBITT, CALLIE
Entity type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:
Last Name:GRAY BOBBITT
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 1:1325 GREENDALE AVE UNIT 41
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1084
Mailing Address - Country:US
Mailing Address - Phone:850-529-8195
Mailing Address - Fax:
Practice Address - Street 1:3686 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-8463
Practice Address - Country:US
Practice Address - Phone:850-892-8035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4206104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767697200Medicaid