Provider Demographics
NPI:1093872103
Name:CONNOLLY, EDWARD LEO (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEO
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 POST RD
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-1615
Mailing Address - Country:US
Mailing Address - Phone:201-405-1991
Mailing Address - Fax:201-581-0376
Practice Address - Street 1:9 POST RD
Practice Address - Street 2:SUITE D-1
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-1615
Practice Address - Country:US
Practice Address - Phone:201-405-1991
Practice Address - Fax:201-581-0376
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00381600103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ10764753OtherCAQH