Provider Demographics
NPI:1033189550
Name:CONNOLLY, LOREN (PHD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LOCH RAVEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239
Mailing Address - Country:US
Mailing Address - Phone:443-444-4034
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:REHAB DEPARTMENT
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000554103T00000X
MD05866103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE005101C60Medicare PIN
DES75072Medicare UPIN