Provider Demographics
NPI:1902253503
Name:CALLISTER, DAVE (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:CALLISTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:DAVID
Other - Last Name:CALLISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:356 APPLE LEAF AVE
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9160 S 300 W STE 3
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2656
Practice Address - Country:US
Practice Address - Phone:801-671-0765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7218184-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical