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General NPI Number Information
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NPI Number | 1073007548
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Entity Type | Individual
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Provider Name | KELLY M CAVANAUGH LMT, CMLDT
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Gender | Female
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Dates
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Enumeration Date | 06/19/2018
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Last Update Date | 06/19/2018
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Provider Practice Location Address
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Address Line | 425 JOLIET ST STE 212
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City | DYER
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State | IN
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Zip | 46311-1766
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Country | US
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Telephone | 219-381-9772
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Fax |
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Provider Business Mailing Address
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Address Line | 618 214TH ST
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City | DYER
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State | IN
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Zip | 46311-1508
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Country | US
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Telephone | 219-381-9772
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT21505529
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License Number State | IN
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