Provider Demographics
NPI:1053021923
Name:MCTAVISH, GAVIN TIMOTHY
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:TIMOTHY
Last Name:MCTAVISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2533
Mailing Address - Country:US
Mailing Address - Phone:240-578-3446
Mailing Address - Fax:
Practice Address - Street 1:1900 N HOWARD ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5909
Practice Address - Country:US
Practice Address - Phone:443-438-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28722104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD28722Medicaid