Provider Demographics
NPI:1124724182
Name:CAUDILL, CAROLINE C
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:C
Last Name:CAUDILL
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 1:771 E RANCH DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5117
Mailing Address - Country:US
Mailing Address - Phone:321-243-1842
Mailing Address - Fax:
Practice Address - Street 1:771 E RANCH DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5117
Practice Address - Country:US
Practice Address - Phone:321-243-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty