Basic Information
| Provider Information | |||||||||
| NPI: | 1609986496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | BETSY | ||||||||
| MiddleName: | NICHOLSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DSW LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLSON | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1782 E HOLLADAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841242606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012723584 | ||||||||
| FaxNumber: | 8012723584 | ||||||||
| Practice Location | |||||||||
| Address1: | LIFESKILLS SUPPORT CTR | ||||||||
| Address2: | HILL AIR FORCE BASE | ||||||||
| City: | HILL AFB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017777909 | ||||||||
| FaxNumber: | 8017774490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1314123501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1314123501 | 01 | UT | LCSW DIV OF OCC. PROF LIC | OTHER |