Healthcare Provider Details

I. General information

NPI: 1578998423
Provider Name (Legal Business Name): ASHLEY MARIE CONNELLY CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35514 INDIGO DR
STERLING HEIGHTS MI
48310-4946
US

IV. Provider business mailing address

30845 EMBASSY ST
BEVERLY HILLS MI
48025-5033
US

V. Phone/Fax

Practice location:
  • Phone: 586-212-2671
  • Fax:
Mailing address:
  • Phone: 248-642-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: