Provider Demographics
NPI:1275023624
Name:CAVANAUGH, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020I PROSPERITY CHURCH RD # 247
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8112
Mailing Address - Country:US
Mailing Address - Phone:910-390-6635
Mailing Address - Fax:888-510-1019
Practice Address - Street 1:1297 PROFESSIONAL DR STE 101B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5713
Practice Address - Country:US
Practice Address - Phone:910-390-6635
Practice Address - Fax:888-510-1019
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician