Provider Demographics
NPI:1184222036
Name:GADDIS, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:GADDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W DIVIDE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1224
Mailing Address - Country:US
Mailing Address - Phone:701-226-0091
Mailing Address - Fax:701-491-7505
Practice Address - Street 1:1221 W DIVIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1224
Practice Address - Country:US
Practice Address - Phone:701-226-0091
Practice Address - Fax:701-491-7505
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician