Provider Demographics
NPI:1740315019
Name:CALLSTROM, RANDY W (LSCSW)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:W
Last Name:CALLSTROM
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7353 FALMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3254
Mailing Address - Country:US
Mailing Address - Phone:913-671-8508
Mailing Address - Fax:913-328-4603
Practice Address - Street 1:1301 N 47TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1705
Practice Address - Country:US
Practice Address - Phone:913-328-4697
Practice Address - Fax:913-328-4603
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-4602Medicare ID - Type Unspecified
KS3620000Medicare ID - Type Unspecified