Provider Demographics
NPI:1255119525
Name:KAVANAGH, KELLY CHRISTINA (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINA
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2417
Mailing Address - Country:US
Mailing Address - Phone:631-258-6130
Mailing Address - Fax:
Practice Address - Street 1:23 CANDEE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3055
Practice Address - Country:US
Practice Address - Phone:631-629-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103044-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker