MEDICARE: MRS. VICTORIA ELIZABETH CONNELLY PT

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	225100000X	Physical Therapist	1375	SC

General Provider Information

NPI Number	:	1619066479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICTORIA ELIZABETH CONNELLY PT

Provider Business Mailing Address
First Line	:	8530 DOAR RD
Second Line	:
City	:	AWENDAW
State	:	SC
Zip	:	29429-6037
Country	:	US
Telephone Number	:	843-884-4783
Fax Number	:	843-884-4783

Provider Business Practice Location Address
First Line	:	570 LONG POINT RD
Second Line	:	SUITE 270
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	24946
Country	:	US
Telephone Number	:	843-884-4783
Fax Number	:	843-884-4783

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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