Provider Demographics
NPI:1184940694
Name:KAVANAUGH, BRENDAN TYRONE (LSW)
Entity type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:TYRONE
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 FLATBUSH AVE # 206
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-2177
Mailing Address - Country:US
Mailing Address - Phone:718-398-0800
Mailing Address - Fax:
Practice Address - Street 1:202 FLATBUSH AVE # 206
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-2177
Practice Address - Country:US
Practice Address - Phone:718-398-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05611600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker