Provider Demographics
NPI:1194704031
Name:KAECK, DANIEL J (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:KAECK
Suffix:
Gender:M
Credentials:PHD
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 1378
Mailing Address - Street 2:SOUTHWESTERN STATE HOSPITAL - PATIENT BILLING DEPARTMEN
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1378
Mailing Address - Country:US
Mailing Address - Phone:229-227-2977
Mailing Address - Fax:229-227-2955
Practice Address - Street 1:400 S PINETREE BLVD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-7128
Practice Address - Country:US
Practice Address - Phone:229-227-2977
Practice Address - Fax:229-227-2955
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000724103TA0700X, 103TB0200X, 103TC1900X, 103TC2200X, 103TF0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBGNTMedicare ID - Type UnspecifiedMEDICARE
GAQ47560Medicare UPIN