Provider Demographics
NPI:1417655325
Name:CADDELL, BEAU ANTHONY (PLMHP)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:ANTHONY
Last Name:CADDELL
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 S 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2445
Mailing Address - Country:US
Mailing Address - Phone:712-216-0164
Mailing Address - Fax:
Practice Address - Street 1:15705 W. DODGE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118
Practice Address - Country:US
Practice Address - Phone:402-575-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health