Provider Demographics
NPI:1164144002
Name:CAMERON, KELLEN JAMES (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:JAMES
Last Name:CAMERON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 GROVE CIR N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2684
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:
Practice Address - Street 1:7767 ELM CREEK BLVD N STE 160
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7078
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:763-201-8192
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist