Provider Demographics
NPI:1760864078
Name:CANAVAN, ALYCIA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 GATEWAY LOOP STE 112
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7723
Mailing Address - Country:US
Mailing Address - Phone:541-371-2782
Mailing Address - Fax:541-804-7695
Practice Address - Street 1:1126 GATEWAY LOOP STE 112
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7723
Practice Address - Country:US
Practice Address - Phone:541-371-2782
Practice Address - Fax:541-804-7695
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
OR15420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500689312Medicaid