Provider Demographics
NPI:1205817541
Name:POLLOCK, CONNIE JEAN (L,ISW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:JEAN
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:L,ISW
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:JEAN
Other - Last Name:BAYNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2197 KYLE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6418
Mailing Address - Country:US
Mailing Address - Phone:937-236-8920
Mailing Address - Fax:937-236-8930
Practice Address - Street 1:4710 OLD TROY PIKE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5740
Practice Address - Country:US
Practice Address - Phone:937-233-1230
Practice Address - Fax:937-236-8930
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00070111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical