Provider Demographics
NPI:1831170695
Name:CANAVAN, DONNA C (OTR/L)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:C
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19653
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9653
Mailing Address - Country:US
Mailing Address - Phone:217-545-0885
Mailing Address - Fax:217-545-2588
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-0885
Practice Address - Fax:217-545-2588
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-002024225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILL67789Medicare ID - Type Unspecified
IL$$$$$$$$$001Medicaid