Provider Demographics
NPI:1629124961
Name:CANALES, LYNNE MARIE (MA)
Entity Type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:MARIE
Last Name:CANALES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 S MALAYA WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-6411
Mailing Address - Country:US
Mailing Address - Phone:303-669-8151
Mailing Address - Fax:
Practice Address - Street 1:5217 S MALAYA WAY
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-6411
Practice Address - Country:US
Practice Address - Phone:303-669-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0245444231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97720364Medicaid