Provider Demographics
NPI:1811312135
Name:CAVANAGH, BRIAN (MS CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:CAVANAGH
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 N EDDY PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-5607
Mailing Address - Country:US
Mailing Address - Phone:208-871-1531
Mailing Address - Fax:
Practice Address - Street 1:5607 N EDDY PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-5607
Practice Address - Country:US
Practice Address - Phone:208-871-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1760235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist