Provider Demographics
NPI:1255718243
Name:MCCALLUM, MONTINIQUE (LCSW)
Entity type:Individual
Prefix:
First Name:MONTINIQUE
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MONTINIQUE
Other - Middle Name:T
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:BLDG 9 1ST FLOOR
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:200 CRESCENT CENTER PKWY STE 150
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7047
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0056911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical