Provider Demographics
NPI:1336625508
Name:STANLEY, CALEB RYAN
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:RYAN
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4294 BOSKYDELL RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-7611
Mailing Address - Country:US
Mailing Address - Phone:662-882-8116
Mailing Address - Fax:
Practice Address - Street 1:4114 N WATER TOWER PL STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6548
Practice Address - Country:US
Practice Address - Phone:662-882-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-17-24990103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst