Provider Demographics
NPI:1588204325
Name:CALDWELL, KIAIRA
Entity type:Individual
Prefix:
First Name:KIAIRA
Middle Name:
Last Name:CALDWELL
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 1:9705 BREVARD ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1920
Mailing Address - Country:US
Mailing Address - Phone:240-778-4403
Mailing Address - Fax:
Practice Address - Street 1:7175 COLUMBIA GATEWAY DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2536
Practice Address - Country:US
Practice Address - Phone:443-620-8278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MDRBT-19-3877-188552106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician