Provider Demographics
NPI:1447620059
Name:CALDWELL, DAVID TIMOTHY (LLC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:TIMOTHY
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 KATHERINE CT
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3659
Mailing Address - Country:US
Mailing Address - Phone:313-402-0894
Mailing Address - Fax:
Practice Address - Street 1:2955 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-5231
Practice Address - Country:US
Practice Address - Phone:313-402-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012840101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health