Basic Information
Provider Information
NPI: 1003004631
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CAVANAUGH
FirstName: TERRY
MiddleName: THOMAS
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 222 TONGASS DR
Address2:  
City: SITKA
State: AK
PostalCode: 998359416
CountryCode: US
TelephoneNumber: 9079668312
FaxNumber:  
Practice Location
Address1: 222 TONGASS DR
Address2:  
City: SITKA
State: AK
PostalCode: 998359416
CountryCode: US
TelephoneNumber: 9079668312
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 06/30/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT423MEY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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