Provider Demographics
NPI:1487994919
Name:CALDWELL, MICAH JR (MS, LPCC, LCPC)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:JR
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:MS, LPCC, LCPC
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:J
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:7301 W 25TH ST # 130
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1409
Mailing Address - Country:US
Mailing Address - Phone:708-695-4841
Mailing Address - Fax:
Practice Address - Street 1:3440 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3322
Practice Address - Country:US
Practice Address - Phone:708-695-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 101YP2500X
IL101Y00000X
WI16627-130101YA0400X
CALPCC5913101YP2500X
IL180.013357101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)