Provider Demographics
NPI:1336121284
Name:CAVANAUGH, SUSAN L (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 HARTFORD TPKE
Mailing Address - Street 2:SUITE U
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4852
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:203-866-3014
Practice Address - Street 1:144 MORGAN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5433
Practice Address - Country:US
Practice Address - Phone:203-965-0609
Practice Address - Fax:203-965-0623
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000386Medicare ID - Type Unspecified