Provider Demographics
NPI:1104858372
Name:CONNOLLY, LAURIE (OT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S I ST
Mailing Address - Street 2:STE 205
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6502
Mailing Address - Country:US
Mailing Address - Phone:360-532-1707
Mailing Address - Fax:360-532-1703
Practice Address - Street 1:100 S I ST
Practice Address - Street 2:STE 205
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6502
Practice Address - Country:US
Practice Address - Phone:360-532-1707
Practice Address - Fax:360-532-1703
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001109208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7681679Medicaid
WAGAB34664OtherMEDICARE PTAN
WA0167363OtherL & I