Provider Demographics
NPI:1275094948
Name:KEADY-CANNON, CAMILLA SUSAN
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:SUSAN
Last Name:KEADY-CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAMILLA
Other - Middle Name:SUSAN
Other - Last Name:KEADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 COMMUNITY WAY
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2301
Mailing Address - Country:US
Mailing Address - Phone:717-393-0425
Mailing Address - Fax:717-735-6009
Practice Address - Street 1:625 COMMUNITY WAY
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2301
Practice Address - Country:US
Practice Address - Phone:717-393-0425
Practice Address - Fax:717-735-6009
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016064225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1037166130001Medicaid