Provider Demographics
NPI:1871230219
Name:CONNELLY, LANCE C
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:C
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 1:1148 PINEHURST LN
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:IA
Mailing Address - Zip Code:50211-1909
Mailing Address - Country:US
Mailing Address - Phone:515-250-6567
Mailing Address - Fax:
Practice Address - Street 1:1148 PINEHURST LN
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:IA
Practice Address - Zip Code:50211-1909
Practice Address - Country:US
Practice Address - Phone:515-250-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA113230101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health