Provider Demographics
NPI:1689706640
Name:CAVANAGH, MARY THERESE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:THERESE
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:CAVANAGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:3486 MOYER RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9566
Mailing Address - Country:US
Mailing Address - Phone:248-634-7383
Mailing Address - Fax:517-468-3423
Practice Address - Street 1:3486 MOYER RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-9566
Practice Address - Country:US
Practice Address - Phone:248-358-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010598201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical