Provider Demographics
NPI:1396977492
Name:MANION, CONNIE SUE
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:SUE
Last Name:MANION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:SUE
Other - Last Name:MANION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:1707 PARK MEADOWS DR
Mailing Address - Street 2:APT. 4
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3768
Mailing Address - Country:US
Mailing Address - Phone:239-689-1320
Mailing Address - Fax:
Practice Address - Street 1:1707 PARK MEADOWS DR
Practice Address - Street 2:APT. 4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3768
Practice Address - Country:US
Practice Address - Phone:239-689-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-23
Last Update Date:2009-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10219224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA10219OtherFLORIDA BOARD OF OCCUPATIONAL THERAPY