Provider Demographics
NPI:1003635517
Name:KAVANAUGH, THEA CAROLYN
Entity type:Individual
Prefix:MRS
First Name:THEA
Middle Name:CAROLYN
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4527 GALISTEO LOOP
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4301
Mailing Address - Country:US
Mailing Address - Phone:575-635-9013
Mailing Address - Fax:
Practice Address - Street 1:4527 GALISTEO LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4301
Practice Address - Country:US
Practice Address - Phone:575-635-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No174H00000XOther Service ProvidersHealth Educator