Provider Demographics
NPI:1194237719
Name:KAVANAGH, ANDREW MICHAEL (MT-BC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2846
Mailing Address - Country:US
Mailing Address - Phone:609-247-5289
Mailing Address - Fax:610-449-5566
Practice Address - Street 1:2050 W CHESTER PIKE STE 115
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2742
Practice Address - Country:US
Practice Address - Phone:610-449-9669
Practice Address - Fax:610-449-5566
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-05
Last Update Date:2017-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11939225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist