Provider Demographics
NPI:1427597475
Name:DAVIS, CAITLIN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:
Other - Last Name:COUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:149 HICKORY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:PALENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12463-2619
Mailing Address - Country:US
Mailing Address - Phone:518-965-2473
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:315-342-7664
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021264-1225X00000X
NY63021264171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05202997Medicaid