Provider Demographics
NPI:1437519352
Name:MICHAEL C CONNOLLY
Entity Type:Organization
Organization Name:MICHAEL C CONNOLLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-234-7803
Mailing Address - Street 1:412 PIPER PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4320
Mailing Address - Country:US
Mailing Address - Phone:904-234-7803
Mailing Address - Fax:
Practice Address - Street 1:8825 PERIMETER PARK BLVD STE 602
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1122
Practice Address - Country:US
Practice Address - Phone:904-234-7803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 4717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty