Provider Demographics
NPI:1194292318
Name:CALLAHAN, WILLIAM PATRICK
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:PATRICK
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 CABRILLO AVE # 203
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2819
Mailing Address - Country:US
Mailing Address - Phone:310-227-4885
Mailing Address - Fax:
Practice Address - Street 1:1855 W KATELLA AVE STE 150
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-3432
Practice Address - Country:US
Practice Address - Phone:714-399-3480
Practice Address - Fax:714-399-3481
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA913744300FOtherMEDI-CAL
CA$$$$$$$$$AMedicaid