Healthcare Provider Details

I. General information

NPI: 1386113231
Provider Name (Legal Business Name): EMILY AUDREY KAVANAGH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PLYMOUTH RD STE 250
PLYMOUTH MI
48170-1842
US

IV. Provider business mailing address

409 PLYMOUTH RD STE 250
PLYMOUTH MI
48170-1842
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-9098
  • Fax:
Mailing address:
  • Phone: 734-416-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015263
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: