Healthcare Provider Details

I. General information

NPI: 1548558695
Provider Name (Legal Business Name): ALLISSA CAUDILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 20TH ST SUITE 205
HUNTINGTON WV
25703-2071
US

IV. Provider business mailing address

1115 20TH ST SUITE 205
HUNTINGTON WV
25703-2071
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1500
  • Fax:
Mailing address:
  • Phone: 304-691-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number129215
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1141
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: