Basic Information
| Provider Information | |||||||||
| NPI: | 1457444002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 TACOMA AVE S | ||||||||
| Address2: | PIERCE COUNTY JAIL: MENTAL HEALTH | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984022105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537984013 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 325 EAST PIONEER AVENUE | ||||||||
| Address2: | MULTICARE GOOD SAMARITAN BEHAVIORAL HEALTH | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983723265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536978400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC60329803 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CG60152051 | 05 | WA | MEDICAID | MC60329803 | 05 | WA | MEDICAID |