Basic Information
| Provider Information | |||||||||
| NPI: | 1831656867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORREGO MACCALLON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACCALLON | ||||||||
| OtherFirstName: | SAMANTH | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1221 W BEN WHITE BLVD STE 210A | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129604533 | ||||||||
| FaxNumber: | 5128873970 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 MANCHACA RD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787453633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129604533 | ||||||||
| FaxNumber: | 5128873970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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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 | 101YP2500X | 72119 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.