Provider Demographics
NPI:1871640326
Name:KAVANAUGH, DOUGLAS P (PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4451 N 26TH ST
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4142
Mailing Address - Country:US
Mailing Address - Phone:402-476-2600
Mailing Address - Fax:402-476-2604
Practice Address - Street 1:4451 N 26TH ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-4142
Practice Address - Country:US
Practice Address - Phone:402-476-2600
Practice Address - Fax:402-476-2604
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE276272Medicare ID - Type Unspecified