Provider Demographics
NPI:1962410860
Name:CALLENDER, THERESA A (LCSW, PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:CALLENDER
Suffix:
Gender:F
Credentials:LCSW, PA-C
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:CALLENDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, PA-C
Mailing Address - Street 1:11 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3061
Mailing Address - Country:US
Mailing Address - Phone:941-320-5454
Mailing Address - Fax:
Practice Address - Street 1:11 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3061
Practice Address - Country:US
Practice Address - Phone:207-373-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW109451041C0700X
MEPA2013363A00000X
FL3324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHX736AOtherMEDICARE PTAN