Provider Demographics
NPI:1508481664
Name:CONNELLY, MATTHEW (LMFT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 N 800 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-2845
Mailing Address - Country:US
Mailing Address - Phone:801-712-7868
Mailing Address - Fax:
Practice Address - Street 1:1258 W SOUTH JORDAN PKWY STE 202
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4712
Practice Address - Country:US
Practice Address - Phone:801-255-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9880965-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist