Provider Demographics
NPI:1861828311
Name:KAVANAUGH, KERRY ANN (BA, RBT)
Entity Type:Individual
Prefix:MRS
First Name:KERRY ANN
Middle Name:
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:BA, RBT
Other - Prefix:MRS
Other - First Name:KERI ANN
Other - Middle Name:
Other - Last Name:KAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6416 NW 5TH WAY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6112
Mailing Address - Country:US
Mailing Address - Phone:888-754-0398
Mailing Address - Fax:
Practice Address - Street 1:6416 NW 5TH WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-6112
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-16-16355106S00000X
FL16-16355106S00000X
222Q00000X
FLRBT-16-16355106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist