Provider Demographics
NPI:1598998700
Name:CANNON, CAROLYN (OT/L)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 N BALTIMORE AVE
Mailing Address - Street 2:SUITE 228
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5454
Mailing Address - Country:US
Mailing Address - Phone:503-477-9527
Mailing Address - Fax:503-477-9529
Practice Address - Street 1:6635 N BALTIMORE AVE
Practice Address - Street 2:SUITE 228
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-5454
Practice Address - Country:US
Practice Address - Phone:503-477-9527
Practice Address - Fax:503-477-9529
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR985071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist