Provider Demographics
NPI:1710149042
Name:CONNELLY, JOHN T JR (PHDLPCLRC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:CONNELLY
Suffix:JR
Gender:M
Credentials:PHDLPCLRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 MADISON AVE
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-2766
Mailing Address - Country:US
Mailing Address - Phone:856-488-6285
Mailing Address - Fax:856-663-4743
Practice Address - Street 1:6500 MADISON AVE
Practice Address - Street 2:SUITE 5B
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-2766
Practice Address - Country:US
Practice Address - Phone:856-488-6285
Practice Address - Fax:856-663-4743
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPC912,RC1012103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral