Provider Demographics
NPI:1669037453
Name:POWDERLY, CAITLIN LARA MADELYN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:LARA MADELYN
Last Name:POWDERLY
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 1:3665 ELOISE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9006
Mailing Address - Country:US
Mailing Address - Phone:978-408-9462
Mailing Address - Fax:
Practice Address - Street 1:3665 ELOISE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-9006
Practice Address - Country:US
Practice Address - Phone:978-408-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
19-84604106S00000X
FL1-21-46989103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician