Provider Demographics
NPI:1689790529
Name:KAVANAUGH, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KAVANAUGH
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 1:2106 S OWINGS ST
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-9011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 NW SAINT MARY DR STE 102
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2539
Practice Address - Country:US
Practice Address - Phone:816-229-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2240OtherLICENSE#