Provider Demographics
NPI:1750358230
Name:CONNOLLY, KATHLEEN RILEY (PT)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:RILEY
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 WOOD LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-1769
Mailing Address - Country:US
Mailing Address - Phone:215-741-9315
Mailing Address - Fax:
Practice Address - Street 1:1262 WOOD LN
Practice Address - Street 2:SUITE 102
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1769
Practice Address - Country:US
Practice Address - Phone:215-741-9315
Practice Address - Fax:215-741-9317
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003468L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011231890001Medicaid
PA2426748000OtherIBC
PA064499Q5SMedicare PIN