Provider Demographics
NPI:1184315665
Name:CAUDLE, WILLIAM TYLER (LMT, CPT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TYLER
Last Name:CAUDLE
Suffix:
Gender:M
Credentials:LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 BRAD MARY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:GA
Mailing Address - Zip Code:30814-3602
Mailing Address - Country:US
Mailing Address - Phone:478-733-4958
Mailing Address - Fax:
Practice Address - Street 1:655 NW FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2459
Practice Address - Country:US
Practice Address - Phone:706-614-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014116225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist