Provider Demographics
NPI:1558383141
Name:BAIN, CONNIE SUE (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:BAIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SMITH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-619-6819
Mailing Address - Fax:513-645-2393
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-312-8100
Practice Address - Fax:937-312-8101
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT001778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2695810Medicaid
OH4192313Medicare PIN
OH4192311Medicare PIN
OH2695810Medicaid
4192312Medicare PIN