Provider Demographics
NPI:1376320234
Name:CANNON, DENISE LYNN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:LYNN
Last Name:CANNON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 S FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2027
Mailing Address - Country:US
Mailing Address - Phone:773-318-8526
Mailing Address - Fax:
Practice Address - Street 1:RIVER VALLEY PHYSICAL THERAPY
Practice Address - Street 2:535 E. NORTH STREET, SUITE C
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-802-7503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.000129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist