Provider Demographics
NPI:1053557959
Name:CAVANAUGH, STACY J (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:J
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BAY RIDGE PKWY
Mailing Address - Street 2:B-4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2307
Mailing Address - Country:US
Mailing Address - Phone:917-250-5124
Mailing Address - Fax:718-238-3462
Practice Address - Street 1:140 BAY RIDGE PKWY
Practice Address - Street 2:B-4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-2307
Practice Address - Country:US
Practice Address - Phone:917-250-5124
Practice Address - Fax:718-238-3462
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011638-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist