Provider Demographics
NPI:1407384985
Name:CAVANAUGH, KATHRYN SUSAN (SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SUSAN
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137A RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2317
Mailing Address - Country:US
Mailing Address - Phone:203-578-5019
Mailing Address - Fax:
Practice Address - Street 1:845 PADDOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7021
Practice Address - Country:US
Practice Address - Phone:203-238-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist