Provider Demographics
NPI:1730749706
Name:GRANGER, CALLA
Entity type:Individual
Prefix:
First Name:CALLA
Middle Name:
Last Name:GRANGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CALLA
Other - Middle Name:
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3458
Mailing Address - Country:US
Mailing Address - Phone:260-482-9125
Mailing Address - Fax:260-481-2838
Practice Address - Street 1:1115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-3616
Practice Address - Country:US
Practice Address - Phone:260-824-1071
Practice Address - Fax:260-824-5578
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003564A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health