Provider Demographics
NPI:1669596623
Name:MCCONNELL, TERESA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 NW CAROL DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3352
Mailing Address - Country:US
Mailing Address - Phone:541-479-2482
Mailing Address - Fax:
Practice Address - Street 1:230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9416
Practice Address - Country:US
Practice Address - Phone:541-582-2323
Practice Address - Fax:541-582-2419
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12691225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist