Provider Demographics
NPI:1679071492
Name:CALDWELL, ADDIE MAE
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:MAE
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:N2150 KESAEHKAHTEK RD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:WI
Mailing Address - Zip Code:54128-9602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N2150 KESAEHKAHTEK RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:WI
Practice Address - Zip Code:54128-9602
Practice Address - Country:US
Practice Address - Phone:715-799-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3331-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional