Provider Demographics
NPI:1891912960
Name:CONNELL, KATIE ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:ELIZABETH
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1978
Mailing Address - Country:US
Mailing Address - Phone:507-202-2932
Mailing Address - Fax:
Practice Address - Street 1:24500 CENTER RIDGE ROAD
Practice Address - Street 2:BUILDING 4, SUITE 100
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44415-5602
Practice Address - Country:US
Practice Address - Phone:440-899-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6502103T00000X, 103TC0700X, 103TF0200X
MN4745103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA030OtherCHAMPUS TRIWEST
MN374T1FAOtherBLUE CROSS BLUE SHIELD OF MN
152304OtherUCARE
680002305Medicare PIN