Provider Demographics
NPI:1689152928
Name:CONNELL, IRENE A (OTR)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:A
Last Name:CONNELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5019
Mailing Address - Country:US
Mailing Address - Phone:541-216-3142
Mailing Address - Fax:
Practice Address - Street 1:255 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-5019
Practice Address - Country:US
Practice Address - Phone:541-216-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1020322OtherNATIONAL BOARD OF CERTIFICATION IN OCCUPATIONAL THERAPY
IDOT-1937OtherTHE OCCUPATIONAL THERAPY LICENSURE BOARD
OR1020322OtherOCCUPATIONAL THERAPY LICENSING BOARD