Healthcare Provider Details

I. General information

NPI: 1902584246
Provider Name (Legal Business Name): TARAH DANIELLE CAUDILL M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/07/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 ROCK DOCK DRIVE
HAZARD KY
41701
US

IV. Provider business mailing address

PO BOX 1089
HAZARD KY
41702-1089
US

V. Phone/Fax

Practice location:
  • Phone: 606-438-8272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number239765
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: