Provider Demographics
NPI:1528429057
Name:KAVANAGH, PRISCILLA LUPITA (LPCC)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:LUPITA
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 NORTH CALIFORNIA ST.
Mailing Address - Street 2:TEAM D
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202
Mailing Address - Country:US
Mailing Address - Phone:209-953-1030
Mailing Address - Fax:209-468-3516
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:530-721-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7094101YP2500X
CAAPCC2122101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional