Provider Demographics
NPI:1487960415
Name:MACCALLUM, ROBERTA C (SLP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:C
Last Name:MACCALLUM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3911
Mailing Address - Country:US
Mailing Address - Phone:207-829-2031
Mailing Address - Fax:
Practice Address - Street 1:75 SOUTH ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1713
Practice Address - Country:US
Practice Address - Phone:207-222-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP828235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist