=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417866641
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE PHUNG OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2026
-----------------------------------------------------
Last Update Date | 09/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30630 RIDGE RD
-----------------------------------------------------
City | WICKLIFFE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44092-1166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-943-2050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 ANSEL RD # 408
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-454-3320
-----------------------------------------------------
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 | OT013878
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------