Provider Demographics
NPI:1710303318
Name:CAVANAGH, LISA CHRISTINE (PSYD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:CAVANAGH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6099 HERON AVE
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3367
Mailing Address - Country:US
Mailing Address - Phone:612-578-4148
Mailing Address - Fax:
Practice Address - Street 1:6099 HERON AVE
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3367
Practice Address - Country:US
Practice Address - Phone:612-578-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1573103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical