Provider Demographics
NPI:1265890248
Name:CAUDELL, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:CAUDELL
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 1:2637 E SPRING HILL CT
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-8594
Mailing Address - Country:US
Mailing Address - Phone:316-755-5250
Mailing Address - Fax:
Practice Address - Street 1:3223 N OLIVER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2106
Practice Address - Country:US
Practice Address - Phone:316-267-5437
Practice Address - Fax:316-267-3456
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1942649116Medicaid