Provider Demographics
NPI:1649459397
Name:KAVANAUGH-WALLACE, LAUREN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:
Last Name:KAVANAUGH-WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18805 W CATAWBA AVE STE 207
Mailing Address - Street 2:PO BOX 361
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4609
Mailing Address - Country:US
Mailing Address - Phone:704-787-4272
Mailing Address - Fax:980-321-7106
Practice Address - Street 1:18805 W CATAWBA AVE
Practice Address - Street 2:STE 207
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4608
Practice Address - Country:US
Practice Address - Phone:704-787-4272
Practice Address - Fax:980-321-7106
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP-3786103T00000X
MI630101257103T00000X
MI6301011257103TC0700X
IL071005134103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical