=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316001266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRESA A. CALDWELL DBA FAMILY NETWORK OF EAST TEXAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 06/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 COUNTY ROAD 256
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-0415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-4365
-----------------------------------------------------
Fax | 936-560-4365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 COUNTY ROAD 256
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-0415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-4365
-----------------------------------------------------
Fax | 936-560-4365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. THRESA ANNETTE CALDWELL
-----------------------------------------------------
Credential | M.A.,LBSW
-----------------------------------------------------
Telephone | 936-560-4365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 27886
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------