Healthcare Provider Details

I. General information

NPI: 1265664528
Provider Name (Legal Business Name): SEAN KEITH CUMMINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2009
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 BIRCH AVE
COTTAGE GROVE OR
97424-1416
US

IV. Provider business mailing address

1345 BIRCH AVE P.O. BOX 5
COTTAGE GROVE OR
97424-1416
US

V. Phone/Fax

Practice location:
  • Phone: 541-942-3939
  • Fax: 541-942-9310
Mailing address:
  • Phone: 541-942-3939
  • Fax: 541-942-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: