Basic Information
| Provider Information | |||||||||
| NPI: | 1073014783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONNON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 PINCH HWY | ||||||||
| Address2: | |||||||||
| City: | POTTERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488768753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177639120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173641000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201009042 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1073588711 | 05 | MI | MEDICAID |