MEDICARE: TERI LYNN CAUDILL PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1252	KY
2	103TC2200X	Clinical Child & Adolescent Psychologist	P.7026	OH
3	103TC0700X	Clinical Psychologist	7026	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000325414	OTHER	KY	ANTHEM BC/BS NUMBER

General Provider Information

NPI Number	:	1164514212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERI LYNN CAUDILL PSY.D.

Provider Business Mailing Address
First Line	:	3333 BURNET AVE
Second Line	:	ML 3015
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3026
Country	:	US
Telephone Number	:	513-636-4336
Fax Number	:	513-636-3677

Provider Business Practice Location Address
First Line	:	3333 BURNET AVE
Second Line	:	ML 3015
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3026
Country	:	US
Telephone Number	:	513-636-4336
Fax Number	:	513-636-3677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	02/12/2021

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