Provider Demographics
NPI:1750665782
Name:CAVANAUGH, STACEY L (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MERCADO ST STE 131
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7318
Mailing Address - Country:US
Mailing Address - Phone:703-882-2000
Mailing Address - Fax:
Practice Address - Street 1:175 MERCADO ST STE 131
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7318
Practice Address - Country:US
Practice Address - Phone:970-382-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9976225100000X
MO2011031127225100000X
CO0014389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO150900048Medicare PIN