Provider Demographics
NPI:1225919210
Name:CALDWELL, CARLY ELAINE (MA, ATR, LASOP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ELAINE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MA, ATR, LASOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:IL
Mailing Address - Zip Code:62048-1020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1808
Practice Address - Country:US
Practice Address - Phone:618-606-7226
Practice Address - Fax:618-505-0785
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023028221101YM0800X
IL24-632221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health