Provider Demographics
NPI:1568935997
Name:KAVANAGH, WILLIAM JOSEPH
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 ROMAINE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-2617
Mailing Address - Country:US
Mailing Address - Phone:323-391-4117
Mailing Address - Fax:
Practice Address - Street 1:6311 ROMAINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-2617
Practice Address - Country:US
Practice Address - Phone:323-391-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98486106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOAT0002968OtherAETNA