Provider Demographics
NPI:1134230071
Name:CAVANAGH, NICOLE (LISW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:BATESBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29006-2600
Mailing Address - Country:US
Mailing Address - Phone:803-405-7217
Mailing Address - Fax:
Practice Address - Street 1:2669 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2911
Practice Address - Country:US
Practice Address - Phone:803-405-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC71531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ33320Medicare UPIN