Provider Demographics
NPI:1588066112
Name:STUDEBAKER, CALLI
Entity type:Individual
Prefix:
First Name:CALLI
Middle Name:
Last Name:STUDEBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 UNIVERSITY BLVD STE E2C
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9149
Mailing Address - Country:US
Mailing Address - Phone:846-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9225 UNIVERSITY BLVD STE E2C
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9149
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:843-569-4535
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid
SCTH3303Medicaid