Provider Demographics
NPI:1043791015
Name:CALDWELL, MARY C (MED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 BLAND CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-4115
Mailing Address - Country:US
Mailing Address - Phone:434-953-5523
Mailing Address - Fax:
Practice Address - Street 1:1407 CROZET AVE
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-2722
Practice Address - Country:US
Practice Address - Phone:434-823-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist