Provider Demographics
NPI:1215223524
Name:EVANS-CHANNELL, HEATHER (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:EVANS-CHANNELL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 CORDOVA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4255 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HILLS
Practice Address - State:OH
Practice Address - Zip Code:44128-2811
Practice Address - Country:US
Practice Address - Phone:216-292-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14048505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist