Healthcare Provider Details

I. General information

NPI: 1487858437
Provider Name (Legal Business Name): DEAN RUSSELL CAULEY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2765 TAMIAMI TRL STE C
PORT CHARLOTTE FL
33952-5163
US

IV. Provider business mailing address

3270 YUKON DR
PORT CHARLOTTE FL
33948-6130
US

V. Phone/Fax

Practice location:
  • Phone: 941-661-8895
  • Fax:
Mailing address:
  • Phone: 941-627-2867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: