Provider Demographics
NPI:1972002780
Name:CANNAVO, BIANCA (MCD-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BIANCA
Middle Name:
Last Name:CANNAVO
Suffix:
Gender:F
Credentials:MCD-CCC-SLP
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:
Other - Last Name:BUSTAMANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD-SLP
Mailing Address - Street 1:935 CONTESSA
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1726
Mailing Address - Country:US
Mailing Address - Phone:909-762-1465
Mailing Address - Fax:
Practice Address - Street 1:1040 WYCLIFFE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-1222
Practice Address - Country:US
Practice Address - Phone:909-762-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12007390200000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program