Provider Demographics
NPI:1174580872
Name:CONNELLY, STACEY GORDON (OTRL CHT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:GORDON
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:OTRL CHT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTRL CHT
Mailing Address - Street 1:424 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3438
Mailing Address - Country:US
Mailing Address - Phone:401-861-2976
Mailing Address - Fax:
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT00892225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI00000291880OtherBCBS OF RI
RI001072OtherBLUE CHIP OF RI