Healthcare Provider Details

I. General information

NPI: 1417142308
Provider Name (Legal Business Name): KIM CAUDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 QUARRIER ST STE 515
CHARLESTON WV
25301-2332
US

IV. Provider business mailing address

PO BOX 11210
CHARLESTON WV
25339-1210
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-9586
  • Fax: 304-344-2169
Mailing address:
  • Phone: 304-346-9596
  • Fax: 304-344-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number953
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: