Provider Demographics
NPI:1871510404
Name:KAVANAUGH, MELINDA SUE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:SUE
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8221
Mailing Address - Street 2:7425 FORSYTH
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-8221
Mailing Address - Country:US
Mailing Address - Phone:314-935-0770
Mailing Address - Fax:314-935-0575
Practice Address - Street 1:517 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1007
Practice Address - Country:US
Practice Address - Phone:314-362-6908
Practice Address - Fax:314-747-3258
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005003884104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
197032OtherMO-BLUE SHIELD