Provider Demographics
NPI:1356471437
Name:CAVANAUGH, JEANETTE MARY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:MARY
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1163
Mailing Address - Country:US
Mailing Address - Phone:781-639-4944
Mailing Address - Fax:781-639-5052
Practice Address - Street 1:599 CANAL ST
Practice Address - Street 2:4 EAST - 17
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1244
Practice Address - Country:US
Practice Address - Phone:978-685-8951
Practice Address - Fax:978-639-5404
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107878101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1890123Medicaid