MEDICARE: MS. CHANNING HEAVENOR CREVELING MA CCC-SLP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA12781	FL
2	235Z00000X	Speech-Language Pathologist	6881	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700805686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHANNING HEAVENOR CREVELING MA CCC-SLP LLC

Provider Business Mailing Address
First Line	:	1746 E SILVER STAR RD STE 133
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-7014
Country	:	US
Telephone Number	:	910-538-2325
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 S HIGHWAY 27 STE B201
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-6816
Country	:	US
Telephone Number	:	352-394-0212
Fax Number	:	352-241-6361

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	10/10/2020

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Directions to “ MS. CHANNING HEAVENOR CREVELING MA CCC-SLP LLC” Practice Location

Language	Start Address	Practice Location

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