Healthcare Provider Details

I. General information

NPI: 1255512307
Provider Name (Legal Business Name): CALDWELL PSYCHOTHERAPY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 ISAAC NEWTON SQ W STE 204
RESTON VA
20190-5040
US

IV. Provider business mailing address

1984 ISAAC NEWTON SQ W STE 204
RESTON VA
20190-5040
US

V. Phone/Fax

Practice location:
  • Phone: 703-863-6140
  • Fax:
Mailing address:
  • Phone: 703-863-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC302452
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090400280
License Number StateVA

VIII. Authorized Official

Name: MR. ROBERT DAVID CALDWELL
Title or Position: OWNER
Credential: LICSW
Phone: 202-298-8311