Provider Demographics
NPI:1548558695
Name:CAUDILL, ALLISSA
Entity Type:Individual
Prefix:
First Name:ALLISSA
Middle Name:
Last Name:CAUDILL
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 1:1115 20TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2071
Mailing Address - Country:US
Mailing Address - Phone:304-691-1500
Mailing Address - Fax:
Practice Address - Street 1:1115 20TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2071
Practice Address - Country:US
Practice Address - Phone:304-691-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129215103T00000X
WV1141103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist