Provider Demographics
NPI:1992963722
Name:CONNELLY, TIMOTHY RICHARD (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-2066
Mailing Address - Country:US
Mailing Address - Phone:210-710-7288
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DRIVE
Practice Address - Street 2:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5349
Practice Address - Country:US
Practice Address - Phone:210-710-7288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist