Provider Demographics
NPI:1225463151
Name:CANAVAN, CHERYL JEANNE (MS, PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:JEANNE
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 KIDDER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06278-1014
Mailing Address - Country:US
Mailing Address - Phone:860-429-4116
Mailing Address - Fax:
Practice Address - Street 1:82 KIDDER BROOK RD
Practice Address - Street 2:
Practice Address - City:ASHFORD
Practice Address - State:CT
Practice Address - Zip Code:06278-1014
Practice Address - Country:US
Practice Address - Phone:860-429-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist