Provider Demographics
NPI:1376895821
Name:CONNELL, AUDREY SUZANNE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:SUZANNE
Last Name:CONNELL
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 1:28 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-3211
Mailing Address - Country:US
Mailing Address - Phone:864-735-0842
Mailing Address - Fax:
Practice Address - Street 1:400 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2251
Practice Address - Country:US
Practice Address - Phone:864-735-0842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC6842101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty