Provider Demographics
NPI:1467415836
Name:CONDLEY, TESS LYNLY (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:TESS
Middle Name:LYNLY
Last Name:CONDLEY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17706 I-30
Mailing Address - Street 2:STE 3
Mailing Address - City:BENTON
Mailing Address - State:AZ
Mailing Address - Zip Code:72015
Mailing Address - Country:US
Mailing Address - Phone:501-315-4414
Mailing Address - Fax:501-315-3467
Practice Address - Street 1:17706 I-30
Practice Address - Street 2:STE 3
Practice Address - City:BENTON
Practice Address - State:AZ
Practice Address - Zip Code:72015
Practice Address - Country:US
Practice Address - Phone:501-315-4414
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1618225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X554OtherBCBS