Provider Demographics
NPI:1447623715
Name:CAVINEE, BRADY (ATC, LAT)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:CAVINEE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203A FALL CREEKWAY E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2442
Mailing Address - Country:US
Mailing Address - Phone:812-212-2208
Mailing Address - Fax:
Practice Address - Street 1:11595 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6947
Practice Address - Country:US
Practice Address - Phone:317-509-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002734A2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer