Healthcare Provider Details

I. General information

NPI: 1336859404
Provider Name (Legal Business Name): GARY CALLAHAN-SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 FOOTHILL BLVD
SAN LEANDRO CA
94578-1013
US

IV. Provider business mailing address

29159 CHUTNEY RD
HAYWARD CA
94544-6732
US

V. Phone/Fax

Practice location:
  • Phone: 510-352-9690
  • Fax:
Mailing address:
  • Phone: 925-390-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: