Provider Demographics
NPI:1891118063
Name:CANADIAN VALLEY SPEECH SERVICES
Entity Type:Organization
Organization Name:CANADIAN VALLEY SPEECH SERVICES
Other - Org Name:DIANN BURRIS' CANADIAN VALLEY SPEECH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANN
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:405-830-4023
Mailing Address - Street 1:12016 SW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7223
Mailing Address - Country:US
Mailing Address - Phone:405-830-4023
Mailing Address - Fax:405-324-5536
Practice Address - Street 1:1100 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7201
Practice Address - Country:US
Practice Address - Phone:405-830-4023
Practice Address - Fax:405-324-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty