Provider Demographics
NPI:1427728427
Name:CALDWELL, DERRICK T (LMBT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:T
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 ELM STREET
Mailing Address - Street 2:SUITE 234
Mailing Address - City:BUNNLEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28323-9244
Mailing Address - Country:US
Mailing Address - Phone:910-514-3111
Mailing Address - Fax:
Practice Address - Street 1:823 ELM STREET
Practice Address - Street 2:SUITE 234
Practice Address - City:BUNNLEVEL
Practice Address - State:NC
Practice Address - Zip Code:28323-9244
Practice Address - Country:US
Practice Address - Phone:910-514-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist