Healthcare Provider Details

I. General information

NPI: 1376230656
Provider Name (Legal Business Name): MICAH CALDWELL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 CLINTON AVE
BERWYN IL
60402-3322
US

IV. Provider business mailing address

7301 W 25TH ST # 130
NORTH RIVERSIDE IL
60546-1409
US

V. Phone/Fax

Practice location:
  • Phone: 708-695-4841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICAH CALDWELL
Title or Position: OWNER/THERAPIST
Credential: LCPC
Phone: 708-695-4841