Provider Demographics
NPI:1346427549
Name:CAVANESS, MIRANDA L (BCBA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:CAVANESS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 ANGELUS ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-2523
Mailing Address - Country:US
Mailing Address - Phone:870-240-3957
Mailing Address - Fax:
Practice Address - Street 1:4101 ANGELUS ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-240-3957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR08-29-AE-PL101Y00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor