Provider Demographics
NPI:1578074381
Name:CAVANAUGH, MELISSA MICHELLE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MICHELLE
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 CAMELLIA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7220
Mailing Address - Country:US
Mailing Address - Phone:337-257-4203
Mailing Address - Fax:
Practice Address - Street 1:1223 CAMELLIA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7220
Practice Address - Country:US
Practice Address - Phone:337-366-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
LA7552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor