Provider Demographics
NPI:1184849317
Name:CONNELLY, DIANNE MARY (PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:MARY
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8955 GUILFORD RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2651
Mailing Address - Country:US
Mailing Address - Phone:443-393-2650
Mailing Address - Fax:443-276-6841
Practice Address - Street 1:8955 GUILFORD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2651
Practice Address - Country:US
Practice Address - Phone:443-393-2650
Practice Address - Fax:443-276-6841
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00111171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH412181-03OtherCAREFIRST NON-PAR NO.