Provider Demographics
NPI:1124233549
Name:P. DOUGLAS CALLAN & ASSOC LTD
Entity type:Organization
Organization Name:P. DOUGLAS CALLAN & ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:CALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-629-6549
Mailing Address - Street 1:1361 N LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8867
Mailing Address - Country:US
Mailing Address - Phone:810-629-6549
Mailing Address - Fax:810-629-0614
Practice Address - Street 1:1361 N LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-8867
Practice Address - Country:US
Practice Address - Phone:810-629-6549
Practice Address - Fax:810-629-0614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2050633OtherCIGNA
MI117163OtherVALUE OPTIONS
MI680B54550-0OtherBLUE CROSS
MI38741455OtherTRICARE
MIIP285944OtherMAGELLAN
MIP99889OtherBLUE CARE NETWORK
MI8915160OtherCIGNA
MIM036569OtherCHAMPUS
MI248189OtherMHN
MI266552OtherHORIZON
MI248189OtherMHN
MI=========OtherCONNECTICUT GENERAL
MI2050633OtherCIGNA
MI266552OtherHORIZON