Provider Demographics
NPI:1649630963
Name:MCCALLUM, SHANTEL
Entity type:Individual
Prefix:MS
First Name:SHANTEL
Middle Name:
Last Name:MCCALLUM
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 1:1441 BOXWOOD BLVD
Mailing Address - Street 2:D18
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1441 BOXWOOD BLVD
Practice Address - Street 2:D18
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2700
Practice Address - Country:US
Practice Address - Phone:706-596-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility