Provider Demographics
NPI:1497884431
Name:CONNOLLY, LORETTA LEDERER (LCSW)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:LEDERER
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LOLLY
Other - Middle Name:LEDERER
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3330 OLD GLENVIEW RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2963
Mailing Address - Country:US
Mailing Address - Phone:847-251-4459
Mailing Address - Fax:847-251-9897
Practice Address - Street 1:3330 OLD GLENVIEW RD
Practice Address - Street 2:SUITE 16
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:847-251-4459
Practice Address - Fax:847-251-9897
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL338180Medicare ID - Type Unspecified