Provider Demographics
NPI:1982824678
Name:CAVANAGH, KELLI A (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SECOND FLOOR SUITE 2
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4300
Mailing Address - Country:US
Mailing Address - Phone:631-864-2819
Mailing Address - Fax:
Practice Address - Street 1:340 VETERANS MEMORIAL HWY
Practice Address - Street 2:SECOND FLOOR SUITE 2
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4300
Practice Address - Country:US
Practice Address - Phone:631-864-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR05747011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY539822OtherVALUE OPTIONS
NYR0574701OtherHIP GREATER NY
NY7347271OtherGHI NY
NY198989OtherMHN
NYP3366199OtherOXFORD