Provider Demographics
NPI:1265167142
Name:CALLOWAY, LUCILLE BELLE
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:BELLE
Last Name:CALLOWAY
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 1:38 WILMA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-1124
Mailing Address - Country:US
Mailing Address - Phone:330-774-7791
Mailing Address - Fax:234-288-9242
Practice Address - Street 1:38 WILMA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-1124
Practice Address - Country:US
Practice Address - Phone:330-774-7791
Practice Address - Fax:234-288-9242
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-23
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4-694-2OtherHEALTH PROVIDER