Basic Information
| Provider Information | |||||||||
| NPI: | 1871510404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAVANAUGH | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8221 | ||||||||
| Address2: | 7425 FORSYTH | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631568221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149350770 | ||||||||
| FaxNumber: | 3149350575 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 S EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143626908 | ||||||||
| FaxNumber: | 3147473258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| 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 | 104100000X | 2005003884 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 197032 | 01 | MO-BLUE SHIELD | OTHER |