Provider Demographics
NPI:1770602641
Name:KALBACK, SHAWN R (PHD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:R
Last Name:KALBACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-872-4303
Mailing Address - Fax:207-872-4294
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-872-4303
Practice Address - Fax:207-872-4294
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04354103TC2200X
MEPS1375103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent