Provider Demographics
NPI:1972624781
Name:CAVNER, BRANDI L (MPT)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:CAVNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 TURF DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1009 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-238-0088
Practice Address - Fax:208-238-0055
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5479460OtherCCN
ID85120066610450OtherREGENCE LIFE & HEALTH
IDTD401OtherBLUE CROSS OF IDAHO
ID731656010OtherTRICARE
ID610872200OtherDOL-ACS OWCP
ID0000-10144181OtherBLUE SHIELD
ID806629100Medicaid
ID5744703OtherFIRST HEALTH
ID7042522OtherAETNA
ID806629100Medicaid