Provider Demographics
NPI:1124249057
Name:CONNOLLY, MARY MADELINE (OTRL)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MADELINE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTRL
Mailing Address - Street 1:391 PROVO ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019
Mailing Address - Country:US
Mailing Address - Phone:619-447-8111
Mailing Address - Fax:
Practice Address - Street 1:251 LANDIS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-498-8450
Practice Address - Fax:619-498-8453
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4695225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty