Provider Demographics
NPI:1346775400
Name:CONNOLLY, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 LAKESIDE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5275
Mailing Address - Country:US
Mailing Address - Phone:775-870-5027
Mailing Address - Fax:
Practice Address - Street 1:3740 LAKESIDE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-5275
Practice Address - Country:US
Practice Address - Phone:775-870-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0498-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)