=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629005681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN STEPHEN CAVANAUGH PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 S BROOM ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19805-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-819-1655
-----------------------------------------------------
Fax | 800-819-1655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4715 VIEWRIDGE AVE STE 230
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-257-8715
-----------------------------------------------------
Fax | 800-819-1655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | B1-0000713
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------