Provider Demographics
NPI:1578899209
Name:CONNOLLY, KATHLEEN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E TREMONT AVE
Mailing Address - Street 2:B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5059
Mailing Address - Country:US
Mailing Address - Phone:704-331-0160
Mailing Address - Fax:704-331-0161
Practice Address - Street 1:218 E TREMONT AVE
Practice Address - Street 2:B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5059
Practice Address - Country:US
Practice Address - Phone:704-331-0160
Practice Address - Fax:704-331-0161
Is Sole Proprietor?:No
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3919101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional