Provider Demographics
NPI:1710448899
Name:CONNEELY, SHEILA MARY
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:MARY
Last Name:CONNEELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 TOWN HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-1144
Mailing Address - Country:US
Mailing Address - Phone:631-513-0121
Mailing Address - Fax:
Practice Address - Street 1:11700 MAIN RD STE 1
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-1525
Practice Address - Country:US
Practice Address - Phone:631-513-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089414104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY089414OtherOTHER