Provider Demographics
NPI:1770517153
Name:CALDWELL, LORE (LCMH)
Entity type:Individual
Prefix:
First Name:LORE
Middle Name:
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:LCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10970
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0970
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:727-322-2110
Practice Address - Street 1:4010 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:727-322-2110
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH537101YM0800X
FLMH11130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024940600Medicaid
NH30422948Medicaid