Provider Demographics
NPI:1467930453
Name:SUSAN CONNELLY LICENSED CLINICAL SOCIAL WORKER, P.C.
Entity Type:Organization
Organization Name:SUSAN CONNELLY LICENSED CLINICAL SOCIAL WORKER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:607-427-4430
Mailing Address - Street 1:515 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5023
Mailing Address - Country:US
Mailing Address - Phone:607-427-4430
Mailing Address - Fax:607-444-3319
Practice Address - Street 1:515 E. MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5023
Practice Address - Country:US
Practice Address - Phone:607-427-4430
Practice Address - Fax:607-444-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043911-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty