Provider Demographics
NPI:1457755357
Name:CAUDILL, DANIEL JOE (PTA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOE
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 CRASES BR
Mailing Address - Street 2:
Mailing Address - City:LETCHER
Mailing Address - State:KY
Mailing Address - Zip Code:41832-9053
Mailing Address - Country:US
Mailing Address - Phone:606-262-4969
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5158
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03262225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant