Provider Demographics
NPI:1689959348
Name:CRECELIUS, CORY RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:RUSSELL
Last Name:CRECELIUS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1243
Mailing Address - Country:US
Mailing Address - Phone:314-583-5553
Mailing Address - Fax:
Practice Address - Street 1:560 COUNTRY CLUB PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6043
Practice Address - Country:US
Practice Address - Phone:541-683-5139
Practice Address - Fax:514-683-5783
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist