Provider Demographics
NPI:1073014783
Name:MCCONNON, THERESA ANNE (MS OTRL)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANNE
Last Name:MCCONNON
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 PINCH HWY
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-8753
Mailing Address - Country:US
Mailing Address - Phone:517-763-9120
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009042225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073588711Medicaid