Healthcare Provider Details

I. General information

NPI: 1417866641
Provider Name (Legal Business Name): CONNIE PHUNG OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30630 RIDGE RD
WICKLIFFE OH
44092-1166
US

IV. Provider business mailing address

1750 ANSEL RD # 408
CLEVELAND OH
44106-4106
US

V. Phone/Fax

Practice location:
  • Phone: 440-943-2050
  • Fax:
Mailing address:
  • Phone: 440-454-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT013878
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: