Basic Information
| Provider Information | |||||||||
| NPI: | 1811668973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CADDELL-SALM | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3115 SEQUOIA WAY | ||||||||
| Address2: | |||||||||
| City: | CLEARLAKE OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954239529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078438930 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39201 STATE ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945381437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662062008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2021 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 106S00000X | Y |
No ID Information.