Provider Demographics
NPI:1699418665
Name:CAVALLO, REBECCA ROSE (LMSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ROSE
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ROSE
Other - Last Name:CAVALLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:225 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 IVY DR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3303
Practice Address - Country:US
Practice Address - Phone:860-459-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4225104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty