Healthcare Provider Details

I. General information

NPI: 1740996172
Provider Name (Legal Business Name): BRYANNA KIELI CALLAHAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

IV. Provider business mailing address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

V. Phone/Fax

Practice location:
  • Phone: 619-585-4221
  • Fax:
Mailing address:
  • Phone: 619-585-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126465
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102371
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number102371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: