Provider Demographics
NPI:1295218428
Name:CONNOLLY, SUSAN KAREN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAREN
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ANCHORS AWEIGH RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-1435
Mailing Address - Country:US
Mailing Address - Phone:339-440-1553
Mailing Address - Fax:
Practice Address - Street 1:38 ANCHORS AWEIGH RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-1435
Practice Address - Country:US
Practice Address - Phone:339-440-1553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1206821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical