Provider Demographics
NPI:1245768647
Name:CONNELL, MICHAEL (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CONNELL
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 N AUSTIN AVE UNIT 405
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3796
Mailing Address - Country:US
Mailing Address - Phone:847-921-0921
Mailing Address - Fax:
Practice Address - Street 1:3375 COMMERCIAL AVE STE 10
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1908
Practice Address - Country:US
Practice Address - Phone:312-438-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106001254106H00000X
IL208000367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist