Provider Demographics
NPI:1538659099
Name:CADDELL, LAURA A (LAC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:A
Last Name:CADDELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BROAD AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1464
Mailing Address - Country:US
Mailing Address - Phone:917-270-8430
Mailing Address - Fax:917-270-8430
Practice Address - Street 1:912 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2336
Practice Address - Country:US
Practice Address - Phone:917-270-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00404700101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor