Provider Demographics
NPI:1770602641
Name:KALBACK, SHAWN R (PHD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:R
Last Name:KALBACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1577 CONGRESS ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2169
Mailing Address - Country:US
Mailing Address - Phone:207-662-5522
Mailing Address - Fax:207-774-1814
Practice Address - Street 1:1577 CONGRESS ST STE 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:207-774-1814
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1375103TC0700X, 103TC2200X
MD04354103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical