Provider Demographics
NPI:1720333008
Name:CAVANESS, KRISTINE J (MA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:J
Last Name:CAVANESS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1376
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-1376
Mailing Address - Country:US
Mailing Address - Phone:084-953-6378
Mailing Address - Fax:
Practice Address - Street 1:1787 WILI PA LOOP
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1280
Practice Address - Country:US
Practice Address - Phone:808-242-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR195164Medicaid