Provider Demographics
NPI:1134116031
Name:CACCAVO, MARY T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:CACCAVO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 SCOTT ST.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:765-448-6226
Mailing Address - Fax:765-448-9416
Practice Address - Street 1:2122 SCOTT ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2932
Practice Address - Country:US
Practice Address - Phone:765-448-6226
Practice Address - Fax:765-448-9416
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001132A237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000202141OtherBCBS UAW
IN000000220890OtherBLUE CROSS BLUE SHIELD
IN000000220890OtherFEDERAL BCBS
IN640004350OtherRAILROAD MEDICARE
IN100232400AMedicaid
IN000000220882OtherBCBS UAW
IN640004350OtherRAILROAD MEDICARE
INR34271Medicare UPIN