Provider Demographics
NPI:1346728714
Name:CONNELL, KATRINA (LISW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2225
Mailing Address - Country:US
Mailing Address - Phone:937-291-2300
Mailing Address - Fax:937-291-2303
Practice Address - Street 1:5563 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2225
Practice Address - Country:US
Practice Address - Phone:937-291-2300
Practice Address - Fax:937-291-2303
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166548101YA0400X
OHS.1903328104100000X
OHI.2304605104100000X, 1041C0700X
OH161761405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333299Medicaid