Provider Demographics
NPI:1124548557
Name:CAVANESS, DESIRAE D (RECOVERY ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:D
Last Name:CAVANESS
Suffix:
Gender:F
Credentials:RECOVERY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 E PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4524
Mailing Address - Country:US
Mailing Address - Phone:501-303-3105
Mailing Address - Fax:
Practice Address - Street 1:1628 E PAGE AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4524
Practice Address - Country:US
Practice Address - Phone:501-303-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator