MEDICARE: PHILLIP EDWARD CALDWELL IV REGISTER MFT INTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1891999561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP EDWARD CALDWELL IV REGISTER MFT INTERN

Provider Business Mailing Address
First Line	:	PO BOX 1127
Second Line	:
City	:	WALNUT GROVE
State	:	CA
Zip	:	95690-1127
Country	:	US
Telephone Number	:	916-477-0028
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 ALBATROSS WAY
Second Line	:	#101
City	:	SACRAMENTO
State	:	CA
Zip	:	95815-2878
Country	:	US
Telephone Number	:	916-631-0771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	07/08/2007

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