Basic Information
| Provider Information | |||||||||
| NPI: | 1336387158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MED, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREGORY | ||||||||
| OtherFirstName: | SALLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1919 LATHROP ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521739 | ||||||||
| FaxNumber: | 9074593810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 LATHROP ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521739 | ||||||||
| FaxNumber: | 9074522384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2009 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 561 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.