Provider Demographics
NPI:1447884218
Name:MANN, KJELL PETER (DPT)
Entity type:Individual
Prefix:
First Name:KJELL
Middle Name:PETER
Last Name:MANN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-1360
Mailing Address - Country:US
Mailing Address - Phone:541-730-4655
Mailing Address - Fax:541-730-4660
Practice Address - Street 1:629 HICKORY ST NW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1758
Practice Address - Country:US
Practice Address - Phone:541-730-4655
Practice Address - Fax:541-730-4660
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11721225100000X
OR63741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty