Provider Demographics
NPI:1891401303
Name:CONNELLY, DOUGLAS WILLIAM (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17421 17TH PL NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5201
Mailing Address - Country:US
Mailing Address - Phone:336-688-1114
Mailing Address - Fax:
Practice Address - Street 1:17421 17TH PL NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5201
Practice Address - Country:US
Practice Address - Phone:336-688-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist