Provider Demographics
NPI:1952189185
Name:CALLOWAY, BENNIE ELGIN III (DMIN, DRE, LCPC)
Entity Type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:ELGIN
Last Name:CALLOWAY
Suffix:III
Gender:M
Credentials:DMIN, DRE, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 E HILL AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-0680
Mailing Address - Country:US
Mailing Address - Phone:229-245-8108
Mailing Address - Fax:
Practice Address - Street 1:2206 E HILL AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-0680
Practice Address - Country:US
Practice Address - Phone:229-245-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22139101YA0400X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)