MEDICARE: DEBRA KAVANAGH PHD

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	103T00000X	Psychologist	PY6392	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54859	OTHER	FL	BLUECROSS

General Provider Information

NPI Number	:	1891754206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA KAVANAGH PHD

Provider Business Mailing Address
First Line	:	4884 61ST CIR
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-6146
Country	:	US
Telephone Number	:	772-532-9728
Fax Number	:

Provider Business Practice Location Address
First Line	:	4884 61ST CIR
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-6146
Country	:	US
Telephone Number	:	772-532-9728
Fax Number	:

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

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	02/01/2010

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