=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972326254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALLIE DEAN LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 N FROST DR STE 2
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48638-5796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-372-1061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 271 S HURON RD
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48634-9482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-450-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6851118934
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------