Provider Demographics
NPI:1881848026
Name:CACCAVALE, JOHN LOUIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:CACCAVALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4662 KATELLA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2654
Mailing Address - Country:US
Mailing Address - Phone:562-342-9999
Mailing Address - Fax:562-342-9991
Practice Address - Street 1:4662 KATELLA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2654
Practice Address - Country:US
Practice Address - Phone:562-342-9999
Practice Address - Fax:562-342-9991
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12880103G00000X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY10761Medicare UPIN
CAWCP12880AMedicare PIN