Provider Demographics
NPI:1497820294
Name:MCAVOY, KERRY KERR (PHD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:KERR
Last Name:MCAVOY
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 1:5060 CASCADE RD SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-454-2911
Mailing Address - Fax:
Practice Address - Street 1:5060 CASCADE RD SE
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-454-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M31200Medicare ID - Type Unspecified