Provider Demographics
NPI:1962554790
Name:CAVANAUGH, AMY E (PHD LLC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:PHD LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 KALISTE SALOOM RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7449
Mailing Address - Country:US
Mailing Address - Phone:337-534-0727
Mailing Address - Fax:337-534-0737
Practice Address - Street 1:3312 KALISTE SALOOM RD BLDG 1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7449
Practice Address - Country:US
Practice Address - Phone:337-534-0727
Practice Address - Fax:337-534-0737
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA998103TB0200X, 103TC1900X, 103TC2200X, 103TC0700X, 103TF0000X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2125541Medicaid