Healthcare Provider Details

I. General information

NPI: 1386055358
Provider Name (Legal Business Name): COURTNEY CAUDILL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY CHILDERS

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

IV. Provider business mailing address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8572
  • Fax: 606-886-4433
Mailing address:
  • Phone: 606-886-8572
  • Fax: 606-886-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253617
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: