Healthcare Provider Details

I. General information

NPI: 1215870258
Provider Name (Legal Business Name): KATHERINE ROSE KAVANAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S STATE ST
ANN ARBOR MI
48109-2201
US

IV. Provider business mailing address

52404 WALNUT DR
CHESTERFIELD MI
48047-4549
US

V. Phone/Fax

Practice location:
  • Phone: 734-647-2583
  • Fax:
Mailing address:
  • Phone: 586-515-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: