Provider Demographics
NPI:1124313382
Name:KAVANAUGH, KATIE FEDERICK (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:FEDERICK
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8101
Mailing Address - Country:US
Mailing Address - Phone:601-529-4211
Mailing Address - Fax:
Practice Address - Street 1:508 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3002
Practice Address - Country:US
Practice Address - Phone:318-878-6376
Practice Address - Fax:318-878-6450
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA89261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical