MEDICARE: ANTRIONNA CAVANAUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310500000X	Mental Illness Intermediate Care Facility		OH

General Provider Information

NPI Number	:	1053029660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTRIONNA CAVANAUGH

Provider Business Mailing Address
First Line	:	PO BOX 350415
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43635-0415
Country	:	US
Telephone Number	:	419-764-7668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 N MCCORD RD APT 45
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-3091
Country	:	US
Telephone Number	:	419-764-7668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2022
Last Update Date	:	11/11/2022

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Directions to “ ANTRIONNA CAVANAUGH ” Practice Location

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