Provider Demographics
NPI:1275654865
Name:CONNOR, ROBERTA LYNN (OTR)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LYNN
Last Name:CONNOR
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 1:1317 TREASURE LK
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-9031
Mailing Address - Country:US
Mailing Address - Phone:814-372-2189
Mailing Address - Fax:
Practice Address - Street 1:1633 PHILIPSBURG BIGLER HWY
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-8112
Practice Address - Country:US
Practice Address - Phone:814-342-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC002008L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014890890001Medicaid