Provider Demographics
NPI:1417024209
Name:CALDWELL COUNSELING ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:CALDWELL COUNSELING ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNDELL
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-880-6127
Mailing Address - Street 1:2020 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4343
Mailing Address - Country:US
Mailing Address - Phone:208-880-6127
Mailing Address - Fax:208-455-6244
Practice Address - Street 1:2020 BLAINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4343
Practice Address - Country:US
Practice Address - Phone:208-880-6127
Practice Address - Fax:208-455-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ1109OtherBLUE CROSS OF ID
ID000010016363OtherREGENCE BLUE SHIELD OF ID