Provider Demographics
NPI:1306226527
Name:CONNOLLY, ROBERT MICHAEL (PT, DPT, MBA)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PT, DPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 N ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-2309
Mailing Address - Country:US
Mailing Address - Phone:301-848-7349
Mailing Address - Fax:
Practice Address - Street 1:4470 REGENCY PL STE 100
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3085
Practice Address - Country:US
Practice Address - Phone:301-645-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30358225100000X
MD26885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist