Healthcare Provider Details

I. General information

NPI: 1043531585
Provider Name (Legal Business Name): SUSANNA LOVE CALLAWAY AU.D., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 44TH ST SW
WYOMING MI
49509-4395
US

IV. Provider business mailing address

3029 WINESAP DR NE
GRAND RAPIDS MI
49525-3155
US

V. Phone/Fax

Practice location:
  • Phone: 616-249-8000
  • Fax: 616-249-8088
Mailing address:
  • Phone: 616-249-8000
  • Fax: 616-249-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000553
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: