Provider Demographics
NPI:1619921483
Name:CONNELL, ROBERT (PSYD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CONNELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 KS HWY 264
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-9365
Mailing Address - Country:US
Mailing Address - Phone:620-285-4229
Mailing Address - Fax:620-285-4509
Practice Address - Street 1:1301 KS HWY 264
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-9365
Practice Address - Country:US
Practice Address - Phone:620-285-4229
Practice Address - Fax:620-285-4509
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS119851Medicare ID - Type Unspecified
Q03728Medicare UPIN