Provider Demographics
NPI:1538887633
Name:CAVANAUGH, BRODY (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:BRODY
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6006 PINEHURST RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2918
Mailing Address - Country:US
Mailing Address - Phone:269-806-0346
Mailing Address - Fax:
Practice Address - Street 1:6006 PINEHURST RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-2918
Practice Address - Country:US
Practice Address - Phone:269-806-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1354103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst