Provider Demographics
NPI:1336387158
Name:CALDWELL, SALLY ANN (LPC-S, MAC, SEP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:LPC-S, MAC, SEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 AIRPORT WAY STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4009
Mailing Address - Country:US
Mailing Address - Phone:907-891-7877
Mailing Address - Fax:907-917-4887
Practice Address - Street 1:1929 AIRPORT WAY STE B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4009
Practice Address - Country:US
Practice Address - Phone:907-891-7877
Practice Address - Fax:907-917-4887
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK507483101YA0400X
AK562101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK13892355OtherCAQH