Provider Demographics
NPI:1093734345
Name:CANAVAN, PATRICIA A (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2817
Mailing Address - Country:US
Mailing Address - Phone:207-768-3304
Mailing Address - Fax:207-764-6340
Practice Address - Street 1:162 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2817
Practice Address - Country:US
Practice Address - Phone:207-768-3304
Practice Address - Fax:207-764-6340
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC8211104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200828OtherANTHEM
ME9454062OtherAETNA
ME1093734345Medicaid
ME1093734345Medicaid