Provider Demographics
NPI:1316376767
Name:CANAVAN, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HAZLE TOWNSHIP BLVD
Mailing Address - Street 2:403 HAZLE TOWNSHIP BLVD
Mailing Address - City:HAZLE TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18202-9661
Mailing Address - Country:US
Mailing Address - Phone:570-454-8888
Mailing Address - Fax:570-459-9252
Practice Address - Street 1:401 HAZLE TOWNSHIP BLVD
Practice Address - Street 2:403 HAZLE TOWNSHIP BLVD
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9661
Practice Address - Country:US
Practice Address - Phone:570-454-8888
Practice Address - Fax:570-459-9252
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist