Provider Demographics
NPI:1750854394
Name:WORSLEY, CONNIE JO
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:JO
Last Name:WORSLEY
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 1:45 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4234
Mailing Address - Country:US
Mailing Address - Phone:937-818-0042
Mailing Address - Fax:
Practice Address - Street 1:515 GRAFTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-5206
Practice Address - Country:US
Practice Address - Phone:937-818-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1130Medicaid