MEDICARE: CALISTA MCCALEB MS CCC-SLP

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	235Z00000X	Speech-Language Pathologist	SA10178	FL

General Provider Information

NPI Number	:	1447761739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALISTA MCCALEB MS CCC-SLP

Provider Business Mailing Address
First Line	:	7962 HAMPTON LAKE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3661
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7962 HAMPTON LAKE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3661
Country	:	US
Telephone Number	:	813-469-3203
Fax Number	:

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

Provider Enumeration Date	:	10/13/2017
Last Update Date	:	10/13/2017

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