Healthcare Provider Details

I. General information

NPI: 1831466457
Provider Name (Legal Business Name): KRISTINA MARIE MCCONNELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 E BEAVERTON RD
CLARE MI
48617-9699
US

IV. Provider business mailing address

107 SCHOOLCREST AVE
CLARE MI
48617-1145
US

V. Phone/Fax

Practice location:
  • Phone: 989-621-7375
  • Fax:
Mailing address:
  • Phone: 989-386-9170
  • Fax: 989-386-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501015653
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: