Provider Demographics
NPI:1437307956
Name:CONNOLLY, CATHLEEN TERESA (PHD)
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:TERESA
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:900 BEACH BLVD
Practice Address - Street 2:SUITE 930
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4368
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-396-8968
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7785103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00754145OtherRAILROAD MEDICARE PART B
FLP00754145OtherRAILROAD MEDICARE PART B