Provider Demographics
NPI:1073251609
Name:CONNELLY, KATHLEEN (LAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08312-1738
Mailing Address - Country:US
Mailing Address - Phone:856-885-0955
Mailing Address - Fax:
Practice Address - Street 1:207 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1703
Practice Address - Country:US
Practice Address - Phone:856-617-4544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00610900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health