MEDICARE: IMMANUEL LEWIS CALLAHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TM1800X	Intellectual & Developmental Disabilities Psychologist	UQ962169	OH

General Provider Information

NPI Number	:	1376252536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMMANUEL LEWIS CALLAHAN

Provider Business Mailing Address
First Line	:	3271 W 115TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-2743
Country	:	US
Telephone Number	:	216-532-9955
Fax Number	:

Provider Business Practice Location Address
First Line	:	3271 W 115TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-2743
Country	:	US
Telephone Number	:	216-532-9955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2022
Last Update Date	:	11/16/2022

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