Provider Demographics
NPI:1003455916
Name:KAVANAUGH, RACQUEL CHERIE
Entity Type:Individual
Prefix:
First Name:RACQUEL
Middle Name:CHERIE
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 SE LAWNFIELD RD APT 22
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9613
Mailing Address - Country:US
Mailing Address - Phone:971-341-4841
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8607
Practice Address - Country:US
Practice Address - Phone:971-341-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ORIN10211971106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600964601Medicaid