Provider Demographics
NPI:1265800916
Name:BURRELL, CALEB
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:BURRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2659 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2007
Mailing Address - Country:US
Mailing Address - Phone:208-284-2312
Mailing Address - Fax:
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2506
Practice Address - Country:US
Practice Address - Phone:209-525-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88505101YP2500X
CALMFT104311106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional