MEDICARE: CONNOR ALLEN DAWS OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.013555	IL
2	225X00000X	Occupational Therapist	6769-26	WI

General Provider Information

NPI Number	:	1063035848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR ALLEN DAWS OTD, OTR/L

Provider Business Mailing Address
First Line	:	1300 EGG HARBOR RD
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1277
Country	:	US
Telephone Number	:	920-746-0410
Fax Number	:	920-746-0244

Provider Business Practice Location Address
First Line	:	1300 EGG HARBOR RD
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1277
Country	:	US
Telephone Number	:	920-746-0410
Fax Number	:	920-746-0244

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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