Provider Demographics
NPI:1275182891
Name:BERAUD, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:BERAUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 LUCAS DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3496
Mailing Address - Country:US
Mailing Address - Phone:903-675-8538
Mailing Address - Fax:
Practice Address - Street 1:711 LUCAS DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3445
Practice Address - Country:US
Practice Address - Phone:903-675-8538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120104225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120104OtherOT BOARD TEXAS