Provider Demographics
NPI:1558502088
Name:CONNOLLY, EILEEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ZAMORA ST
Mailing Address - Street 2:APT 1
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1710
Mailing Address - Country:US
Mailing Address - Phone:585-455-1112
Mailing Address - Fax:
Practice Address - Street 1:28 ZAMORA ST
Practice Address - Street 2:APT 1
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1710
Practice Address - Country:US
Practice Address - Phone:585-455-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist