Basic Information
Provider Information | |||||||||
NPI: | 1770837411 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAVANAGH | ||||||||
FirstName: | ALYSS | ||||||||
MiddleName: | LIAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A., LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIAN | ||||||||
OtherFirstName: | ALYSS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 109 OAK ST | ||||||||
Address2: | SUITE G 10 | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 024641492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 109 OAK ST | ||||||||
Address2: | SUITE G 10 | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 024641492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174674523 | ||||||||
FaxNumber: | 6179165081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2012 | ||||||||
LastUpdateDate: | 11/02/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 005310 | NY | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.