Provider Demographics
NPI:1780115691
Name:KAVANAUGH, COURTNEY R (OTR)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:R
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:885-324-0885
Mailing Address - Fax:765-450-6664
Practice Address - Street 1:17390 DUGDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1512
Practice Address - Country:US
Practice Address - Phone:574-400-2169
Practice Address - Fax:765-450-6664
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006277A225X00000X
IN31006277225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
378069OtherBOARD CERTIFICATION
IN200196020AMedicaid