Healthcare Provider Details

I. General information

NPI: 1982963393
Provider Name (Legal Business Name): MICHAEL MCCALEB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 S EAGLE RD
MERIDIAN ID
83642-6707
US

IV. Provider business mailing address

4297 N CHATTERTON AVE
BOISE ID
83713-1934
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-7334
  • Fax:
Mailing address:
  • Phone: 208-322-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberNONE - INTERN STUDEN
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: