Provider Demographics
NPI:1003355546
Name:CONNOLLY, RACHAEL L
Entity type:Individual
Prefix:MISS
First Name:RACHAEL
Middle Name:L
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 HELLE BLVD APT 115
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9414
Mailing Address - Country:US
Mailing Address - Phone:916-470-6105
Mailing Address - Fax:
Practice Address - Street 1:1975 W M 21
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-8163
Practice Address - Country:US
Practice Address - Phone:810-373-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
7401002440103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst