Healthcare Provider Details

I. General information

NPI: 1861597445
Provider Name (Legal Business Name): MACIE IRENE CAUDILL LPC, MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 NEAL ST STE D
COOKEVILLE TN
38501-4307
US

IV. Provider business mailing address

1330 NEAL ST STE D
COOKEVILLE TN
38501-4307
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-6803
  • Fax: 931-528-6826
Mailing address:
  • Phone: 931-528-6803
  • Fax: 931-528-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0795
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2311
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: