Provider Demographics
NPI:1801380902
Name:CONNOLLY, REBECCA RENEE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RENEE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:RENEE
Other - Last Name:CRISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6511 SPRING BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-3709
Mailing Address - Country:US
Mailing Address - Phone:845-871-3434
Mailing Address - Fax:
Practice Address - Street 1:6511 SPRING BROOK AVE
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-3709
Practice Address - Country:US
Practice Address - Phone:845-871-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016538-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016538-1OtherNYS LICENSE
NY12035440OtherASHA