Healthcare Provider Details

I. General information

NPI: 1700406576
Provider Name (Legal Business Name): STEPHEN ROGERS CAUDILL BS, TCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 US HIGHWAY 68 STE 900
MAYSVILLE KY
41056-9190
US

IV. Provider business mailing address

123 E 3RD ST APT 1
MAYSVILLE KY
41056-1746
US

V. Phone/Fax

Practice location:
  • Phone: 606-584-7055
  • Fax:
Mailing address:
  • Phone: 606-584-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: