Provider Demographics
NPI:1093042905
Name:KAVANAGH, RENE' LE'ANN (LMP)
Entity Type:Individual
Prefix:
First Name:RENE'
Middle Name:LE'ANN
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S W 152ND ST.
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2213
Mailing Address - Country:US
Mailing Address - Phone:206-244-1466
Mailing Address - Fax:206-246-4636
Practice Address - Street 1:612 S W 152ND ST.
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2213
Practice Address - Country:US
Practice Address - Phone:206-244-1466
Practice Address - Fax:206-246-4636
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020230225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist