Provider Demographics
NPI:1497857338
Name:KAVANAUGH, JAMES MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 COUNTY ROAD 243
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8381
Mailing Address - Country:US
Mailing Address - Phone:970-317-5014
Mailing Address - Fax:
Practice Address - Street 1:2243 MAIN AVE STE 4F
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4699
Practice Address - Country:US
Practice Address - Phone:505-995-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44683553Medicaid