MEDICARE: CALLISTA FRYE PSYD

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	103TC0700X	Clinical Psychologist	T-LP 2099	KS
2	390200000X	Student in an Organized Health Care Education/Training Program	B7715996	CA
3	103TC0700X	Clinical Psychologist	PSY29061	CA

General Provider Information

NPI Number	:	1306032982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALLISTA FRYE PSYD

Provider Business Mailing Address
First Line	:	5905 LAKE EARL DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95532-0001
Country	:	US
Telephone Number	:	805-704-7617
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 LAKE EARL DR
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95532-5353
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:

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

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	11/15/2023

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