Basic Information
| Provider Information | |||||||||
| NPI: | 1265434914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 PAYNE ST | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133461111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158250180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4567 CROSSROADS PARK DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152952100 | ||||||||
| FaxNumber: | 3152952126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 014006 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02190590 | 05 | NY | MEDICAID |