Provider Demographics
NPI:1518034925
Name:CONNOLLY, IRENE MIZOBE X (PT, MS)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MIZOBE
Last Name:CONNOLLY
Suffix:X
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N 3RD ST
Mailing Address - Street 2:BOX 302
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4517
Mailing Address - Country:US
Mailing Address - Phone:609-922-0814
Mailing Address - Fax:
Practice Address - Street 1:45 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4508
Practice Address - Country:US
Practice Address - Phone:609-922-0814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006318L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT006318LOtherPA LICENSE