Provider Demographics
NPI:1508312505
Name:KAVANAUGH, KEVIN JAMES (PSYD, PSY)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:PSYD, PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 W BLUEMOUND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5906
Mailing Address - Country:US
Mailing Address - Phone:480-860-7889
Mailing Address - Fax:
Practice Address - Street 1:2901 W BELTLINE HWY STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-4228
Practice Address - Country:US
Practice Address - Phone:630-885-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005986103TC0700X
WI5075-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical