Provider Demographics
NPI:1154637601
Name:MULLOY, CONNIE JEAN (OTR)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:JEAN
Last Name:MULLOY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9136 GOSHEN PARK PL
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20882-1320
Mailing Address - Country:US
Mailing Address - Phone:240-683-5437
Mailing Address - Fax:
Practice Address - Street 1:9136 GOSHEN PARK PL
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20882-1320
Practice Address - Country:US
Practice Address - Phone:240-683-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist