Provider Demographics
NPI:1619228103
Name:CONNELLY, RICHARD T (LCPC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 257
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090
Mailing Address - Country:US
Mailing Address - Phone:207-641-5345
Mailing Address - Fax:207-451-9791
Practice Address - Street 1:518 US ROUTE 1 UNIT 5
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-2500
Practice Address - Country:US
Practice Address - Phone:207-641-5345
Practice Address - Fax:207-451-9791
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4388101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional