Provider Demographics
NPI:1790151272
Name:MCCONNELL, AMY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 W 78TH CT
Mailing Address - Street 2:APT 10
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8704
Mailing Address - Country:US
Mailing Address - Phone:317-442-8711
Mailing Address - Fax:
Practice Address - Street 1:3930 W 78TH CT
Practice Address - Street 2:APT 10
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8704
Practice Address - Country:US
Practice Address - Phone:317-442-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007244A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165490152Medicare PIN