Provider Demographics
NPI:1447380712
Name:KAVANAUGH, CRYSTAL LOUISE (LPE (PROVISIONAL))
Entity Type:Individual
Prefix:MR
First Name:CRYSTAL
Middle Name:LOUISE
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:LPE (PROVISIONAL)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 251970
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1970
Mailing Address - Country:US
Mailing Address - Phone:501-666-8686
Mailing Address - Fax:501-660-6830
Practice Address - Street 1:5905 FOREST PL
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-5244
Practice Address - Country:US
Practice Address - Phone:501-666-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPROVISIONAL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health