Provider Demographics
NPI:1790278422
Name:MCCONNELL, COREY RUSSELL (LISW-S)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:RUSSELL
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 EXECUTIVE PKWY STE 2D
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-5534
Mailing Address - Country:US
Mailing Address - Phone:567-343-8743
Mailing Address - Fax:
Practice Address - Street 1:3130 EXECUTIVE PKWY STE 2D
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-5534
Practice Address - Country:US
Practice Address - Phone:567-343-8743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2203927-SUPV1041C0700X
OHS.20049071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical