Provider Demographics
NPI:1336387158
Name:CALDWELL, SALLY ANN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-452-1739
Mailing Address - Fax:907-459-3810
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 220
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-452-1739
Practice Address - Fax:907-452-2384
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health