Provider Demographics
NPI:1659536415
Name:CANADAY, MARY JO (MS, CCC-A/SP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:CANADAY
Suffix:
Gender:F
Credentials:MS, CCC-A/SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 N MAIN ST UNIT 10
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9681
Mailing Address - Country:US
Mailing Address - Phone:574-247-6047
Mailing Address - Fax:574-247-6060
Practice Address - Street 1:6910 N MAIN ST UNIT 10
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:574-247-6047
Practice Address - Fax:574-247-6060
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004688A235Z00000X
IN23002434A237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200014070Medicaid
IN200014070Medicaid