Provider Demographics
NPI:1073007548
Name:CAVANAUGH, KELLY M (LMT, CMLDT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 214TH ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1508
Mailing Address - Country:US
Mailing Address - Phone:219-381-9772
Mailing Address - Fax:
Practice Address - Street 1:425 JOLIET ST STE 212
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1766
Practice Address - Country:US
Practice Address - Phone:219-381-9772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21505529225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist