Provider Demographics
NPI:1689119026
Name:CAVANAUGH, TED
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:OR
Mailing Address - Zip Code:97738-2576
Mailing Address - Country:US
Mailing Address - Phone:541-573-1780
Mailing Address - Fax:
Practice Address - Street 1:120 S ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:OR
Practice Address - Zip Code:97738-2576
Practice Address - Country:US
Practice Address - Phone:541-573-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health