Provider Demographics
NPI:1417907080
Name:CANCADE, TANYA KAYE (MPT)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:KAYE
Last Name:CANCADE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1081
Mailing Address - Country:US
Mailing Address - Phone:304-295-7290
Mailing Address - Fax:304-295-5922
Practice Address - Street 1:1605 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1081
Practice Address - Country:US
Practice Address - Phone:304-295-7290
Practice Address - Fax:304-295-5922
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT001849225100000X
OH010898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00638940OtherRAILROAD MEDICARE
WV3810002353Medicaid
OH2552858Medicaid
4167702Medicare PIN