Healthcare Provider Details

I. General information

NPI: 1528429057
Provider Name (Legal Business Name): PRISCILLA LUPITA KAVANAGH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 NORTH CALIFORNIA ST. TEAM D
STOCKTON CA
95202
US

V. Phone/Fax

Practice location:
  • Phone: 530-721-1169
  • Fax:
Mailing address:
  • Phone: 209-953-1030
  • Fax: 209-468-3516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: