Healthcare Provider Details

I. General information

NPI: 1184017055
Provider Name (Legal Business Name): CHRIS CAVANAUGH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 DENALI ST STE 450
ANCHORAGE AK
99503-2754
US

IV. Provider business mailing address

2600 DENALI ST STE 450
ANCHORAGE AK
99503-2754
US

V. Phone/Fax

Practice location:
  • Phone: 907-561-0552
  • Fax:
Mailing address:
  • Phone: 907-561-0552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number911
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number148339
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: