Provider Demographics
NPI:1417283615
Name:CONNOLLY, MARY (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1812
Mailing Address - Country:US
Mailing Address - Phone:718-344-4981
Mailing Address - Fax:
Practice Address - Street 1:92 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-1812
Practice Address - Country:US
Practice Address - Phone:718-344-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6072764103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6072764OtherSTATE CERTIFICATATE LMSW