Healthcare Provider Details

I. General information

NPI: 1124249057
Provider Name (Legal Business Name): MARY MADELINE CONNOLLY OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEE CONNOLLY OTRL

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LANDIS AVE SUITE 201
CHULA VISTA CA
91910
US

IV. Provider business mailing address

391 PROVO ST
EL CAJON CA
92019
US

V. Phone/Fax

Practice location:
  • Phone: 619-498-8450
  • Fax: 619-498-8453
Mailing address:
  • Phone: 619-447-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number4695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: