=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154852721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE CAULK PHD, LMHC, LPC,
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 04/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17315 MANCHESTER RD
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63038-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-735-3517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 FAIRLAKE DR
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-7104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-391-6124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2019009805
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------