Provider Demographics
NPI:1700805686
Name:CREVELING, CHANNING HEAVENOR (MA CCC-SLP LLC)
Entity type:Individual
Prefix:MS
First Name:CHANNING
Middle Name:HEAVENOR
Last Name:CREVELING
Suffix:
Gender:F
Credentials:MA CCC-SLP LLC
Other - Prefix:MS
Other - First Name:CHANNING
Other - Middle Name:HEAVENOR
Other - Last Name:CREVELING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:1746 E SILVER STAR RD STE 133
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-7014
Mailing Address - Country:US
Mailing Address - Phone:910-538-2325
Mailing Address - Fax:
Practice Address - Street 1:2400 S HIGHWAY 27 STE B201
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6816
Practice Address - Country:US
Practice Address - Phone:352-394-0212
Practice Address - Fax:352-241-6361
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12781235Z00000X
NC6881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412500Medicaid
FL104167600Medicaid