Provider Demographics
NPI:1417016908
Name:CONNELLY, PATRICK R (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:R
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3069 ENGLISH CREEK AVE
Mailing Address - Street 2:SUITE 224
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-9708
Mailing Address - Country:US
Mailing Address - Phone:609-780-3570
Mailing Address - Fax:
Practice Address - Street 1:3069 ENGLISH CREEK AVE
Practice Address - Street 2:SUITE 224
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-9708
Practice Address - Country:US
Practice Address - Phone:609-780-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05182000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ063726Medicare ID - Type Unspecified