Provider Demographics
NPI:1548784739
Name:MCCONNELL, AUSTIN HARLAND (LMT)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:HARLAND
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5263
Mailing Address - Country:US
Mailing Address - Phone:304-483-7347
Mailing Address - Fax:
Practice Address - Street 1:2100 CAMDEN AVE STE 2
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5669
Practice Address - Country:US
Practice Address - Phone:304-483-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2016-3397225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist