Provider Demographics
NPI:1417142308
Name:CAUDELL, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CAUDELL
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:PO BOX 11210
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1210
Mailing Address - Country:US
Mailing Address - Phone:304-346-9596
Mailing Address - Fax:304-344-2169
Practice Address - Street 1:1021 QUARRIER ST STE 515
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2332
Practice Address - Country:US
Practice Address - Phone:304-346-9586
Practice Address - Fax:304-344-2169
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009722Medicaid