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General NPI Number Information
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NPI Number | 1881093706
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Entity Type | Organization
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Legal Business Name | CALLA CLINIC, LLC
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Dates
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Enumeration Date | 08/15/2014
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 164 SAGAMORE PKWY W
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City | WEST LAFAYETTE
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State | IN
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Zip | 47906-1569
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Country | US
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Telephone | 765-427-5758
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Fax | 866-871-7013
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Provider Business Mailing Address
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Address Line | 164 SAGAMORE PKWY W
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City | WEST LAFAYETTE
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State | IN
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Zip | 47906-1569
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Country | US
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Telephone | 765-427-5758
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Fax | 866-871-7013
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Authorized Official
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Title or Position | OWNER / CLINICAL DIRECTOR
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Name | LISA BRADLEY WERTH
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Credential | LCSW
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Telephone | 765-427-5758
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 87000637A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34004717A
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License Number State | IN
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