1104943414 NPI number — MRS. SANDRA KATHLEEN CAVANAUGH PT

Table of content: MRS. SANDRA KATHLEEN CAVANAUGH PT (NPI 1104943414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104943414 NPI number — MRS. SANDRA KATHLEEN CAVANAUGH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAVANAUGH
Provider First Name:
SANDRA
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BECK
Provider Other First Name:
SANDRA
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104943414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 SUMMER RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19446-6710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-361-7378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 N BROAD ST
Provider Second Line Business Practice Location Address:
ELM TERRACE GARDENS
Provider Business Practice Location Address City Name:
LANSDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19446-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-362-6087
Provider Business Practice Location Address Fax Number:
215-412-3495
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT006901L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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