Provider Demographics
NPI:1164555827
Name:CAVANAGH, REGINA ANNE (MFT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:ANNE
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 HORIZON AVE
Mailing Address - Street 2:APT. #1
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41942106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist