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General NPI Number Information
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NPI Number | 1396714234
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Entity Type | Organization
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Legal Business Name | KATE KAVANAUGH, MA LP, PA
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 06/03/2014
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Provider Practice Location Address
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Address Line | 9531 W. 78TH STREET SUITE 110
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344
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Country | US
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Telephone | 952-893-9791
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Fax | 952-841-7069
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Provider Business Mailing Address
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Address Line | 9531 W. 78TH STREET SUITE 110
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344
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Country | US
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Telephone | 952-893-9791
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Fax | 952-841-7069
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. KATHLEEN MARIE KAVANAUGH
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Credential | MA LP
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Telephone | 952-893-9791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP2468
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License Number State | MN
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