MEDICARE: LISA CHRISTINE CAVANAGH PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY-1573	HI

General Provider Information

NPI Number	:	1710303318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA CHRISTINE CAVANAGH PSY.D.

Provider Business Mailing Address
First Line	:	6099 HERON AVE
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3367
Country	:	US
Telephone Number	:	612-578-4148
Fax Number	:

Provider Business Practice Location Address
First Line	:	6099 HERON AVE
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3367
Country	:	US
Telephone Number	:	612-578-4148
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2014
Last Update Date	:	10/04/2019

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