Provider Demographics
NPI:1407838758
Name:CONNOLLY, KEVIN V (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:V
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 OAKESDALE AVE SW
Mailing Address - Street 2:STE 104
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5226
Mailing Address - Country:US
Mailing Address - Phone:425-228-5336
Mailing Address - Fax:425-228-4540
Practice Address - Street 1:600 OAKESDALE AVE SW
Practice Address - Street 2:STE 104
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5226
Practice Address - Country:US
Practice Address - Phone:425-228-5336
Practice Address - Fax:425-228-4540
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPY00001058103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000106440Medicaid