MEDICARE: KORINA CALLAHAN M.ED, BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-17-25608	AZ

General Provider Information

NPI Number	:	1295249464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORINA CALLAHAN M.ED, BCBA, LBA

Provider Business Mailing Address
First Line	:	2615 E HEIDI LOOP
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-1845
Country	:	US
Telephone Number	:	765-586-2723
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 E HEIDI LOOP
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-1845
Country	:	US
Telephone Number	:	765-586-2723
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2017
Last Update Date	:	11/27/2017

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