Provider Demographics
NPI:1104197938
Name:HAXBY, CONNIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:HAXBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CHENOWETH LN
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2641
Mailing Address - Country:US
Mailing Address - Phone:502-439-5323
Mailing Address - Fax:502-415-7152
Practice Address - Street 1:125 CHENOWETH LN
Practice Address - Street 2:SUITE 111
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2641
Practice Address - Country:US
Practice Address - Phone:502-439-5323
Practice Address - Fax:502-415-7152
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical