Provider Demographics
NPI:1982948238
Name:CANAVAN, TRACI (OTR/L, ATRIC)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:OTR/L, ATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-5041
Mailing Address - Country:US
Mailing Address - Phone:203-988-5191
Mailing Address - Fax:
Practice Address - Street 1:26 RIVER RD
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-5041
Practice Address - Country:US
Practice Address - Phone:203-988-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist