Healthcare Provider Details

I. General information

NPI: 1346768579
Provider Name (Legal Business Name): ALEXANDRA KAVANAUGH LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 UNION SQ W STE 1328
NEW YORK NY
10003-3252
US

IV. Provider business mailing address

404 E 79TH ST APT 4F
NEW YORK NY
10075-1481
US

V. Phone/Fax

Practice location:
  • Phone: 347-670-3774
  • Fax:
Mailing address:
  • Phone: 917-763-6593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number002522
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: