Healthcare Provider Details

I. General information

NPI: 1598394314
Provider Name (Legal Business Name): CATHERINE CALLAHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 02/23/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 WOODBURY RD
GREENVILLE GA
30222
US

IV. Provider business mailing address

122 C GORDON COMMERCIAL DRIVE
LAGRANGE GA
30240
US

V. Phone/Fax

Practice location:
  • Phone: 706-672-1118
  • Fax: 706-672-1918
Mailing address:
  • Phone: 706-845-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178013547
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180012896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: