Healthcare Provider Details

I. General information

NPI: 1649701061
Provider Name (Legal Business Name): ERICA JEAN CALLAHAN L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 HAMILTON ST. SUITE 205 SOUTH BAY EARLY CHILDHOOD,
HARTFORD CT
06106
US

IV. Provider business mailing address

1115 WEST CHESTNUT STREET SOUTH BAY COMMUNITY SERVICES,
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 860-578-1300
  • Fax:
Mailing address:
  • Phone: 860-578-1300
  • Fax: 860-951-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4743
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: