Provider Demographics
NPI:1083320030
Name:ALLISON, CODY SHANE (BS, ACSM-CEP)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:SHANE
Last Name:ALLISON
Suffix:
Gender:M
Credentials:BS, ACSM-CEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 ELLIOT ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-1064
Mailing Address - Country:US
Mailing Address - Phone:503-507-9124
Mailing Address - Fax:
Practice Address - Street 1:930 SW ABBEY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4820
Practice Address - Country:US
Practice Address - Phone:541-574-4856
Practice Address - Fax:541-768-9417
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1066339224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist