Provider Demographics
NPI:1538475140
Name:BACON, TRISHA DANIELLE (DPT)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:DANIELLE
Last Name:BACON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:DANIELLE
Other - Last Name:MACCONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2645 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-266-3658
Mailing Address - Fax:
Practice Address - Street 1:2645 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-266-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR068902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic