Provider Demographics
NPI:1760949556
Name:CONNELLY, DAN JAMES
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:JAMES
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 SW HALL BLVD APT 68
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5779
Mailing Address - Country:US
Mailing Address - Phone:206-972-7191
Mailing Address - Fax:
Practice Address - Street 1:6200 SW ARCTIC DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-9447
Practice Address - Country:US
Practice Address - Phone:503-224-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst