Provider Demographics
NPI:1366866295
Name:CAUDLE, MICAH (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:CAUDLE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-777-9950
Mailing Address - Fax:928-777-9975
Practice Address - Street 1:1223 WILLOW CREED RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1427
Practice Address - Country:US
Practice Address - Phone:928-777-9950
Practice Address - Fax:928-777-9975
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5674225X00000X
NV14-0450225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083794Medicaid
AZZ198693Medicare PIN