Healthcare Provider Details

I. General information

NPI: 1851752521
Provider Name (Legal Business Name): BRIAN KAVANAUGH PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

IV. Provider business mailing address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1359
  • Fax:
Mailing address:
  • Phone: 401-432-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS01545
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: