Provider Demographics
NPI:1033236732
Name:MCCONNELL, MARY DELTA (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DELTA
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 NORTHWOODS DRIVE
Mailing Address - Street 2:PO BOX 1366
Mailing Address - City:MERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97532
Mailing Address - Country:US
Mailing Address - Phone:541-476-8599
Mailing Address - Fax:
Practice Address - Street 1:275 NORTHWOODS DRIVE
Practice Address - Street 2:
Practice Address - City:MERLIN
Practice Address - State:OR
Practice Address - Zip Code:97532
Practice Address - Country:US
Practice Address - Phone:541-476-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist