Provider Demographics
NPI:1013394105
Name:CONNELLY, TERRELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 OLDE MCKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7268
Mailing Address - Country:US
Mailing Address - Phone:919-633-1157
Mailing Address - Fax:
Practice Address - Street 1:1508 OLDE MCKENZIE DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7268
Practice Address - Country:US
Practice Address - Phone:919-633-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3371225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant