Provider Demographics
NPI:1306518535
Name:CACCAVALE, ELIZABETH (LAT, ATC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CACCAVALE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 GAIL CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3813
Mailing Address - Country:US
Mailing Address - Phone:631-356-9756
Mailing Address - Fax:
Practice Address - Street 1:94 GAIL CT
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-3813
Practice Address - Country:US
Practice Address - Phone:631-356-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2255A2300X, 390200000X
MD20000507392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program