Provider Demographics
NPI:1386135085
Name:MCCONNELL, KATHLEEN (CMT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 N SAN MATEO DR STE 5
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2585
Mailing Address - Country:US
Mailing Address - Phone:650-784-5681
Mailing Address - Fax:
Practice Address - Street 1:327 N SAN MATEO DR STE 5
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2585
Practice Address - Country:US
Practice Address - Phone:650-784-5681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist