Provider Demographics
NPI:1720265267
Name:KAVANAGH, CINDY JO (CADC I, AS, QMHA)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:JO
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:CADC I, AS, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15610 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2002
Mailing Address - Country:US
Mailing Address - Phone:971-202-7897
Mailing Address - Fax:503-760-7463
Practice Address - Street 1:15610 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2002
Practice Address - Country:US
Practice Address - Phone:971-202-7897
Practice Address - Fax:503-760-7463
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OR14-05-17U101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator