Provider Demographics
NPI:1154658698
Name:CONNELLY, MARY CATHERINE (BSN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 W OUTER DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2614
Mailing Address - Country:US
Mailing Address - Phone:313-966-9095
Mailing Address - Fax:
Practice Address - Street 1:6001 W OUTER DR
Practice Address - Street 2:SUITE 114
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2614
Practice Address - Country:US
Practice Address - Phone:313-966-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704078229163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult