Provider Demographics
NPI:1982131314
Name:CALLENDER, MICHAEL E (LCPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CALLENDER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 S MALACHITE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6394
Mailing Address - Country:US
Mailing Address - Phone:323-304-7950
Mailing Address - Fax:
Practice Address - Street 1:799 S MALACHITE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6394
Practice Address - Country:US
Practice Address - Phone:208-350-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6558101YM0800X
IDLCPC-9688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1982131314Medicaid