Provider Demographics
NPI:1164890786
Name:CONNER, RHETA DENISE (CTRS)
Entity Type:Individual
Prefix:
First Name:RHETA
Middle Name:DENISE
Last Name:CONNER
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 N 600 E
Mailing Address - Street 2:
Mailing Address - City:AVILLA
Mailing Address - State:IN
Mailing Address - Zip Code:46710-9616
Mailing Address - Country:US
Mailing Address - Phone:260-750-5748
Mailing Address - Fax:
Practice Address - Street 1:247 N 600 E
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-9616
Practice Address - Country:US
Practice Address - Phone:260-750-5748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN52268225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist