Provider Demographics
NPI:1285102061
Name:KAVANAGH, LISA MARIE (LPC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 E HIDDENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7476
Mailing Address - Country:US
Mailing Address - Phone:480-547-0416
Mailing Address - Fax:
Practice Address - Street 1:4023 E HIDDENVIEW DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7476
Practice Address - Country:US
Practice Address - Phone:480-547-0416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700795101YM0800X
AZLPC-20221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health