1740686724 NPI number — CAITLIN J.C. MCAVOY LCSW

Table of content: CAITLIN J.C. MCAVOY LCSW (NPI 1740686724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740686724 NPI number — CAITLIN J.C. MCAVOY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCAVOY
Provider First Name:
CAITLIN
Provider Middle Name:
J.C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROSS
Provider Other First Name:
CAITLIN
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740686724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51 DEPOT ST
Provider Second Line Business Mailing Address:
SUITE 202 UNIT D
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-465-2869
Provider Business Mailing Address Fax Number:
877-805-9529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 DEPOT ST
Provider Second Line Business Practice Location Address:
SUITE 202 UNIT D
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-465-2869
Provider Business Practice Location Address Fax Number:
877-805-9529
Provider Enumeration Date:
11/18/2014

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: 104100000X , with the licence number:  1679 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 9738 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008060327 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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