Healthcare Provider Details

I. General information

NPI: 1356619795
Provider Name (Legal Business Name): BAILEY ELLISON DENNO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. BAILEY ELLISON MASON

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 NW 2ND ST
CORVALLIS OR
97330-6487
US

IV. Provider business mailing address

PO BOX 382
TANGENT OR
97389-0382
US

V. Phone/Fax

Practice location:
  • Phone: 503-926-3338
  • Fax: 503-961-7742
Mailing address:
  • Phone: 503-926-3338
  • Fax: 503-961-7742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number6729
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: