Provider Demographics
NPI:1164540316
Name:CONNOLLY, MEDRIA LOU (PHD)
Entity Type:Individual
Prefix:DR
First Name:MEDRIA
Middle Name:LOU
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2444 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5808
Mailing Address - Country:US
Mailing Address - Phone:310-264-2602
Mailing Address - Fax:310-264-2601
Practice Address - Street 1:2444 WILSHIRE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5808
Practice Address - Country:US
Practice Address - Phone:310-264-2602
Practice Address - Fax:310-264-2601
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9977103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist