Provider Demographics
NPI:1518502442
Name:CAVANAUGH, MADELYN LEIGH (AT)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:LEIGH
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S WASHINGTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2159
Mailing Address - Country:US
Mailing Address - Phone:317-764-0011
Mailing Address - Fax:
Practice Address - Street 1:4501 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2601
Practice Address - Country:US
Practice Address - Phone:240-315-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
OK12852255A2300X
MDA00015462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program