Provider Demographics
NPI:1487968574
Name:KAVANAGH, ELIZABETH (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 TRACELAND DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4200
Mailing Address - Country:US
Mailing Address - Phone:662-680-3148
Mailing Address - Fax:
Practice Address - Street 1:176 HWY 9 NORTH
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:MS
Practice Address - Zip Code:38915
Practice Address - Country:US
Practice Address - Phone:662-412-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1225225100000X
ALPTH1467225100000X
FLPT22065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist