Provider Demographics
NPI:1508497512
Name:CONNOLLY, ELIZABETH ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:VA
Mailing Address - Zip Code:24066-0125
Mailing Address - Country:US
Mailing Address - Phone:908-892-2974
Mailing Address - Fax:
Practice Address - Street 1:301 ELM AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4001
Practice Address - Country:US
Practice Address - Phone:540-345-9841
Practice Address - Fax:540-527-2900
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040114501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid