Provider Demographics
NPI:1255512307
Name:CALDWELL PSYCHOTHERAPY CENTER, PC
Entity type:Organization
Organization Name:CALDWELL PSYCHOTHERAPY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:202-298-8311
Mailing Address - Street 1:1984 ISAAC NEWTON SQ W STE 204
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5040
Mailing Address - Country:US
Mailing Address - Phone:703-863-6140
Mailing Address - Fax:
Practice Address - Street 1:1984 ISAAC NEWTON SQ W STE 204
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5040
Practice Address - Country:US
Practice Address - Phone:703-863-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3024521041C0700X
VA0904002801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC766367ZBR9 G02714OtherMEDICARE PTAN
VA766367ZBR9 G02714OtherMEDICARE PTAN