Provider Demographics
NPI:1548385628
Name:CONNELLY, HEIDI (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:11 MAPLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:ME
Mailing Address - Zip Code:04282-3779
Mailing Address - Country:US
Mailing Address - Phone:207-225-2784
Mailing Address - Fax:
Practice Address - Street 1:11 MAPLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:TURNER
Practice Address - State:ME
Practice Address - Zip Code:04282-3779
Practice Address - Country:US
Practice Address - Phone:207-225-2784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC8130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100332OtherANTHEM BC AND BS