Basic Information
| Provider Information | |||||||||
| NPI: | 1790273696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8303 CORRISON RD | ||||||||
| Address2: | |||||||||
| City: | GRAND LEDGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488378215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179203588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173641000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 08/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201009446 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 106215 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.