Provider Demographics
NPI:1609016369
Name:CONNELLY, HEATHER J
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:949-833-2237
Mailing Address - Fax:559-692-2020
Practice Address - Street 1:6177 N THESTA ST STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-275-0559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor