Provider Demographics
NPI:1164191631
Name:CONNELLY, MICHELLE SCARLETT (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SCARLETT
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 VIA TORNASOL
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-5635
Mailing Address - Country:US
Mailing Address - Phone:408-761-0104
Mailing Address - Fax:
Practice Address - Street 1:1093 VIA TORNASOL
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-5635
Practice Address - Country:US
Practice Address - Phone:408-761-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10382235Z00000X
NV3094235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist