Basic Information
| Provider Information | |||||||||
| NPI: | 1225177546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAVANAGH | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | P-LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9523 LAGUNA AVE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280273553 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 N 1ST ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280012833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049832117 | ||||||||
| FaxNumber: | 7049832636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P003615 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P003615 | 01 | NC | P-LCSW | OTHER |