=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295857258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULA ANN CONNOLLY-CLOSE OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 UNION AVE
-----------------------------------------------------
City | LAKEHURST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08733-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-657-5741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 SAINT CLAIR AVE
-----------------------------------------------------
City | SPRING LAKE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07762-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-359-6175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 46TR00004500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------