Basic Information
| Provider Information | |||||||||
| NPI: | 1962775734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCALLUM | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | SMITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15127 S 73RD AVE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003616880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9414 ROUTE 176 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003616880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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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 | 101Y00000X | 178.005657 | IL | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.