Provider Demographics
NPI:1063563245
Name:CALLAHAN, MARK (LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12421 HESPERIA RD STE 2
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7704
Mailing Address - Country:US
Mailing Address - Phone:607-686-4742
Mailing Address - Fax:
Practice Address - Street 1:12421 HESPERIA RD STE 2
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7704
Practice Address - Country:US
Practice Address - Phone:760-243-5417
Practice Address - Fax:760-780-4591
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106759106H00000X
106H00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist