Provider Demographics
NPI:1891999561
Name:CALDWELL, PHILLIP EDWARD IV (REGISTER MFT INTERN)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EDWARD
Last Name:CALDWELL
Suffix:IV
Gender:M
Credentials:REGISTER MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:WALNUT GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95690-1127
Mailing Address - Country:US
Mailing Address - Phone:916-477-0028
Mailing Address - Fax:
Practice Address - Street 1:2445 ALBATROSS WAY
Practice Address - Street 2:#101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-2878
Practice Address - Country:US
Practice Address - Phone:916-631-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health