Provider Demographics
NPI:1063530160
Name:CALLISTER, TAMI BLASTING (SLP)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:BLASTING
Last Name:CALLISTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HARROWGATE WAY
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4031
Mailing Address - Country:US
Mailing Address - Phone:518-782-1178
Mailing Address - Fax:518-782-3433
Practice Address - Street 1:623 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4031
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:518-782-3433
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist