Provider Demographics
NPI:1518573021
Name:CAVYAN, TINA (ATC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CAVYAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 PERSIMMON CT
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1586
Mailing Address - Country:US
Mailing Address - Phone:847-502-4743
Mailing Address - Fax:
Practice Address - Street 1:500 W ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-4272
Practice Address - Country:US
Practice Address - Phone:847-718-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0032972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer