Provider Demographics
NPI:1801914361
Name:CONNOLLY, JOHN (RPT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5449
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:700 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3244
Practice Address - Country:US
Practice Address - Phone:309-827-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist