Provider Demographics
NPI:1144737362
Name:CONNOLLY, MICHAEL B (CATC II)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:CATC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 AMBER CT
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1710
Mailing Address - Country:US
Mailing Address - Phone:510-253-3645
Mailing Address - Fax:
Practice Address - Street 1:4645 PACHECO BLVD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3625
Practice Address - Country:US
Practice Address - Phone:925-646-9270
Practice Address - Fax:925-646-9276
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA179638261QR0405X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA179638OtherCAADE