Provider Demographics
NPI:1174741557
Name:CONERLY, R L JR (OT)
Entity type:Individual
Prefix:
First Name:R L
Middle Name:
Last Name:CONERLY
Suffix:JR
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-0666
Mailing Address - Country:US
Mailing Address - Phone:601-441-9165
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:800-517-6935
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA2379225200000X
MSOT1963225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist