Provider Demographics
NPI:1356788723
Name:CANNON, KIRSTIN REBEKAH NORDMARK (OTR/L)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:REBEKAH NORDMARK
Last Name:CANNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1573
Mailing Address - Country:US
Mailing Address - Phone:815-404-7257
Mailing Address - Fax:
Practice Address - Street 1:1002 OAK VALLEY DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-1573
Practice Address - Country:US
Practice Address - Phone:815-404-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010152225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist