Provider Demographics
NPI:1760521801
Name:CONNELLY, CAROLYN SUE (LMHP, LIMHP, LADC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:SUE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LMHP, LIMHP, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 WALSH DR
Mailing Address - Street 2:
Mailing Address - City:BOYS TOWN
Mailing Address - State:NE
Mailing Address - Zip Code:68010-7529
Mailing Address - Country:US
Mailing Address - Phone:402-498-3358
Mailing Address - Fax:402-498-3375
Practice Address - Street 1:13460 WALSH DR
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7529
Practice Address - Country:US
Practice Address - Phone:402-498-3358
Practice Address - Fax:402-498-3375
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE727101Y00000X
NE3053101Y00000X
NE753101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660631Medicaid