Provider Demographics
NPI:1205458999
Name:ICANBERRY, DAVID ALEXANDER (SLP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALEXANDER
Last Name:ICANBERRY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9721 12TH PL SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-1992
Mailing Address - Country:US
Mailing Address - Phone:510-919-4029
Mailing Address - Fax:
Practice Address - Street 1:16710 SMOKEY POINT BLVD STE 402
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8435
Practice Address - Country:US
Practice Address - Phone:360-363-4234
Practice Address - Fax:360-363-4235
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60976960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist