Provider Demographics
NPI:1962500504
Name:CONNELLAN, KEVIN M (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:CONNELLAN
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:97 BARNES RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1885
Practice Address - Country:US
Practice Address - Phone:203-793-7592
Practice Address - Fax:203-793-7397
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT7235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007235OtherSTATE LICENSE