Provider Demographics
NPI:1619652641
Name:CONNOLLY, HEIDI (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 S CONGRESS AVE APT 2122
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5100
Mailing Address - Country:US
Mailing Address - Phone:737-318-2569
Mailing Address - Fax:
Practice Address - Street 1:2020 S CONGRESS AVE APT 2122
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5100
Practice Address - Country:US
Practice Address - Phone:737-318-2569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119991235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist