Provider Demographics
NPI:1336287275
Name:CONNALLY, GENA HELEN (PHD)
Entity Type:Individual
Prefix:MRS
First Name:GENA
Middle Name:HELEN
Last Name:CONNALLY
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 1:1175 N BEACHVIEW DR # 133
Mailing Address - Street 2:
Mailing Address - City:JEKYLL ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31527-0704
Mailing Address - Country:US
Mailing Address - Phone:478-743-1472
Mailing Address - Fax:
Practice Address - Street 1:1175 N BEACHVIEW DR # 133
Practice Address - Street 2:
Practice Address - City:JEKYLL ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31527-0704
Practice Address - Country:US
Practice Address - Phone:478-743-1472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA-1253103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA519934819AMedicaid