Healthcare Provider Details

I. General information

NPI: 1639936974
Provider Name (Legal Business Name): EMILY ARCHER CONNELLY MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18115 N US HIGHWAY 41 STE 800
LUTZ FL
33549-6475
US

IV. Provider business mailing address

18115 N US HIGHWAY 41 STE 800
LUTZ FL
33549-6475
US

V. Phone/Fax

Practice location:
  • Phone: 813-848-0341
  • Fax:
Mailing address:
  • Phone: 813-848-0341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number24896
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: