Provider Demographics
NPI:1184641052
Name:KAVANAGH, TRACEY (LMHC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 APPIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0040
Mailing Address - Country:US
Mailing Address - Phone:904-318-2258
Mailing Address - Fax:
Practice Address - Street 1:1000 RIVERSIDE AVE STE 312
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4174
Practice Address - Country:US
Practice Address - Phone:904-318-2258
Practice Address - Fax:904-808-1472
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4678101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor