Basic Information
| Provider Information | |||||||||
| NPI: | 1982153235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | CALLI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANKINS | ||||||||
| OtherFirstName: | CALLI | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2025 W PARK PL STE B | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086205210 | ||||||||
| FaxNumber: | 2086645346 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838549049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086180787 | ||||||||
| FaxNumber: | 2086255641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-36100 | ID | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.