Provider Demographics
NPI:1073677233
Name:CALDWELL, PHILLIP GENTRY (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:GENTRY
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6906 HAMILTON CT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1213
Mailing Address - Country:US
Mailing Address - Phone:703-838-4455
Mailing Address - Fax:703-838-5070
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-4455
Practice Address - Fax:703-838-5070
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040055301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA299089OtherAMERIGROUP VIRGINIA, INC
VA0108OtherCAREFIRST BCBS
VA188809OtherANTHEM
VA011475A25Medicare ID - Type Unspecified