Provider Demographics
NPI:1144230699
Name:KAVESH, LAURA BEATRICE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BEATRICE
Last Name:KAVESH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3204
Mailing Address - Country:US
Mailing Address - Phone:207-662-2221
Mailing Address - Fax:207-662-6348
Practice Address - Street 1:216 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-662-2221
Practice Address - Fax:207-662-6348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1119Medicare PIN