Provider Demographics
NPI:1720570385
Name:CONNELLY, TIMOTHY JACOB (RBT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JACOB
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 ROSIN CT STE 110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1698
Mailing Address - Country:US
Mailing Address - Phone:916-829-6975
Mailing Address - Fax:
Practice Address - Street 1:630 BERCUT DR STE C
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0110
Practice Address - Country:US
Practice Address - Phone:916-363-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-27197106S00000X
CAB9221177171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician