Provider Demographics
NPI:1902591894
Name:KAVTARADZE, THERESE MARIAM
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIAM
Last Name:KAVTARADZE
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 1:144 MOSES CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5673
Mailing Address - Country:US
Mailing Address - Phone:732-859-6223
Mailing Address - Fax:
Practice Address - Street 1:144 MOSES CREEK BLVD
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5673
Practice Address - Country:US
Practice Address - Phone:732-859-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician