Provider Demographics
NPI:1497892392
Name:CONNOLLY, SALLY R (LCSW, LMFT)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:R
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 DOUGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1928
Mailing Address - Country:US
Mailing Address - Phone:502-473-0766
Mailing Address - Fax:
Practice Address - Street 1:2054 DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1928
Practice Address - Country:US
Practice Address - Phone:502-473-0766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3711041C0700X
KY182106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist