Provider Demographics
NPI:1992391254
Name:KAVANAUGH, SEAN PATRICK (LICSW)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:
Practice Address - Street 1:124 E PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1518
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61248749104100000X
MTBBH-SWLC-LIC-43230104100000X
WASC61246297104100000X, 390200000X
WALW613379451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program