Provider Demographics
NPI:1497011217
Name:CONNELLY, THERESA MARCELES
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARCELES
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5613 N HIWASSEE RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-9413
Mailing Address - Country:US
Mailing Address - Phone:405-610-6540
Mailing Address - Fax:405-610-6563
Practice Address - Street 1:351 N AIR DEPOT BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1700
Practice Address - Country:US
Practice Address - Phone:405-610-6540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)