Provider Demographics
NPI:1437871035
Name:CONNELLY, CASSANDRA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARIE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:116 HILLS PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2438
Practice Address - Country:US
Practice Address - Phone:304-720-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV390200000X
WV1328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program