Healthcare Provider Details

I. General information

NPI: 1528484870
Provider Name (Legal Business Name): KELLIE C CANNON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 01/31/2025
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RIVER RD
EUGENE OR
97404
US

IV. Provider business mailing address

1000 RIVER RD
EUGENE OR
97404
US

V. Phone/Fax

Practice location:
  • Phone: 541-689-0935
  • Fax: 541-461-6884
Mailing address:
  • Phone: 541-689-0935
  • Fax: 541-461-6884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60483
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number60483
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: