Provider Demographics
NPI:1780854026
Name:CONNELLY, WILLIAM T (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:T
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:1709 KY ROUTE 321
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9097
Mailing Address - Country:US
Mailing Address - Phone:606-886-8546
Mailing Address - Fax:606-886-8548
Practice Address - Street 1:7629 KY ROUTE 979
Practice Address - Street 2:
Practice Address - City:GRETHEL
Practice Address - State:KY
Practice Address - Zip Code:41631-6304
Practice Address - Country:US
Practice Address - Phone:606-587-2200
Practice Address - Fax:606-587-2203
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY5741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100099340Medicaid
KY00871006Medicare PIN