Provider Demographics
NPI:1649870668
Name:KAVANAGH, LOURDES MAE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:MAE
Last Name:KAVANAGH
Suffix:
Gender:
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 30TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-4769
Mailing Address - Country:US
Mailing Address - Phone:320-556-3222
Mailing Address - Fax:
Practice Address - Street 1:410 30TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4769
Practice Address - Country:US
Practice Address - Phone:320-255-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27800104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker