Provider Demographics
NPI:1609416247
Name:CONNOR, KATHIE THAYER (LMT)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:THAYER
Last Name:CONNOR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3016
Mailing Address - Country:US
Mailing Address - Phone:315-681-7902
Mailing Address - Fax:
Practice Address - Street 1:93 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2626
Practice Address - Country:US
Practice Address - Phone:315-681-7902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist