Provider Demographics
NPI:1396505731
Name:WILMORE, CALLIE (MS)
Entity type:Individual
Prefix:MS
First Name:CALLIE
Middle Name:
Last Name:WILMORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 MANHATTAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5133
Mailing Address - Country:US
Mailing Address - Phone:901-413-1307
Mailing Address - Fax:
Practice Address - Street 1:1149 W 190TH ST STE 2300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4350
Practice Address - Country:US
Practice Address - Phone:310-892-5812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18989235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist