Provider Demographics
NPI:1508465014
Name:CONNELLY, MARIE ISABEL
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ISABEL
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 BROADWAY # 1125
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-2507
Mailing Address - Country:US
Mailing Address - Phone:312-766-6780
Mailing Address - Fax:312-261-5080
Practice Address - Street 1:34 LAWNSBURY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5213
Practice Address - Country:US
Practice Address - Phone:585-261-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NYP126494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician