Provider Demographics
NPI:1760553135
Name:CAMERON, KELLY ANN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:CAMERON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 KANEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2578
Mailing Address - Country:US
Mailing Address - Phone:630-584-1411
Mailing Address - Fax:630-513-2630
Practice Address - Street 1:2525 KANEVILLE RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2578
Practice Address - Country:US
Practice Address - Phone:630-584-1411
Practice Address - Fax:630-513-2630
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070013565OtherSTATE LIC