Provider Demographics
NPI:1154041523
Name:CAULDER, BRANDON ROSS (LCAS-A, LCSWA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROSS
Last Name:CAULDER
Suffix:
Gender:M
Credentials:LCAS-A, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6431
Practice Address - Country:US
Practice Address - Phone:910-343-0145
Practice Address - Fax:910-341-5779
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-065-011101YA0400X, 1041C0700X, 171M00000X
NCP0195961041C0700X
NC28472101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300416TMedicaid