Provider Demographics
NPI:1861837742
Name:MC CONNELL, DEREK J (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:MC CONNELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:
Practice Address - Street 1:1325 WARREN AVE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2566
Practice Address - Country:US
Practice Address - Phone:732-449-7855
Practice Address - Fax:732-449-7856
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01449100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist