Provider Demographics
NPI:1356692792
Name:KAVANAUGH, SHANE ANDREW (MS, LMHC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ANDREW
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-7042
Mailing Address - Country:US
Mailing Address - Phone:515-661-4210
Mailing Address - Fax:
Practice Address - Street 1:125 S 3RD ST
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-7042
Practice Address - Country:US
Practice Address - Phone:515-661-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001560101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health