Provider Demographics
NPI:1396714234
Name:KATE KAVANAUGH, MA LP, PA
Entity type:Organization
Organization Name:KATE KAVANAUGH, MA LP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MA LP
Authorized Official - Phone:952-893-9791
Mailing Address - Street 1:9531 W. 78TH STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344
Mailing Address - Country:US
Mailing Address - Phone:952-893-9791
Mailing Address - Fax:952-841-7069
Practice Address - Street 1:9531 W. 78TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:952-893-9791
Practice Address - Fax:952-841-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2468103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN440053400OtherMEDICAL ASSISTANCE
MN61-16357OtherMEDICA
MN472664907OtherVALUEOPTIONS
MN29G42KAOtherBCBS