Healthcare Provider Details

I. General information

NPI: 1225919210
Provider Name (Legal Business Name): CARLY ELAINE CALDWELL MA, ATR, LASOP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN ST
TROY IL
62294-1808
US

IV. Provider business mailing address

303 S MAIN ST
TROY IL
62294-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-0956
  • Fax: 618-505-0785
Mailing address:
  • Phone: 618-899-0956
  • Fax: 618-505-0785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number24-632
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2023028221
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: