Provider Demographics
NPI:1639942220
Name:CALDWELL, RENATA SHANTE (LCPC, LSOTP)
Entity Type:Individual
Prefix:MS
First Name:RENATA
Middle Name:SHANTE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:LCPC, LSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W STE 950
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5010
Mailing Address - Country:US
Mailing Address - Phone:618-233-3205
Mailing Address - Fax:618-233-1407
Practice Address - Street 1:2900 FRANK SCOTT PKWY W STE 950
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5010
Practice Address - Country:US
Practice Address - Phone:618-233-3205
Practice Address - Fax:618-233-1407
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL270.000208101YP2500X
IL180.015603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional