Provider Demographics
NPI:1922328780
Name:KAVANAGH, NICOLE LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 S FAWN AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-0848
Mailing Address - Country:US
Mailing Address - Phone:480-518-7073
Mailing Address - Fax:
Practice Address - Street 1:5783 S FAWN AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-0848
Practice Address - Country:US
Practice Address - Phone:480-518-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018711235Z00000X
AZSLP6798235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty