Healthcare Provider Details

I. General information

NPI: 1427246164
Provider Name (Legal Business Name): MATTHEW CAUDILL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 05/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 SCENIC HWY
LAWRENCEVILLE GA
30046-5675
US

IV. Provider business mailing address

521 FAIRWAY DR
WOODSTOCK GA
30189-6195
US

V. Phone/Fax

Practice location:
  • Phone: 678-442-5857
  • Fax: 678-442-5915
Mailing address:
  • Phone: 770-362-3077
  • Fax: 770-672-0669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSW003821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: