Individual
MRS. COURTNEY R KAVANAUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
17390 DUGDALE DR, SOUTH BEND, IN 46635-1512
(574) 400-2169
(765) 450-6664
Mailing address
3500 DEPAUW BLVD STE 3070, INDIANAPOLIS, IN 46268-6135
(885) 324-0885
(765) 450-6664
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
31006277
IN
225X00000X
Occupational Therapist
31006277A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200196020A
—
IN
01
—
378069
BOARD CERTIFICATION
—
Enumeration date
03/22/2017
Last updated
07/21/2022
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