Provider Demographics
NPI:1942534284
Name:CANNON, COLT KEITH (COTA)
Entity Type:Individual
Prefix:MR
First Name:COLT
Middle Name:KEITH
Last Name:CANNON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 MILL OAK DR.
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062
Mailing Address - Country:US
Mailing Address - Phone:812-661-0009
Mailing Address - Fax:
Practice Address - Street 1:9730 PRAIRIE LAKES BLVD E
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4766
Practice Address - Country:US
Practice Address - Phone:317-770-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001386A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant