Provider Demographics
NPI:1619743697
Name:CONNELLY, BRIAN PAT
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAT
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2858 RIVERS BEND DR E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8509
Mailing Address - Country:US
Mailing Address - Phone:701-866-9934
Mailing Address - Fax:701-404-8274
Practice Address - Street 1:3523 45TH ST S STE 136
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8962
Practice Address - Country:US
Practice Address - Phone:701-347-1782
Practice Address - Fax:701-404-8274
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2530235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist