Basic Information
| Provider Information | |||||||||
| NPI: | 1770602641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALBACK | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078724303 | ||||||||
| FaxNumber: | 2078724294 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078724303 | ||||||||
| FaxNumber: | 2078724294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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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 | 103TC2200X | 04354 | MD | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | PS1375 | ME | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.