Provider Demographics
NPI:1689000325
Name:CONNELLY, JOHN THOMAS (OT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRL
Mailing Address - Street 2:STE 103
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9204
Mailing Address - Country:US
Mailing Address - Phone:941-743-6700
Mailing Address - Fax:941-743-6707
Practice Address - Street 1:4161 TAMIAMI TRL
Practice Address - Street 2:STE 103
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9204
Practice Address - Country:US
Practice Address - Phone:941-743-6700
Practice Address - Fax:941-743-6707
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist