Provider Demographics
NPI:1013698836
Name:CONNELLY, KAITLYN ROSE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:CONNELLY
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 1:1000 N VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1000
Mailing Address - Country:US
Mailing Address - Phone:516-350-2095
Mailing Address - Fax:
Practice Address - Street 1:1000 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1000
Practice Address - Country:US
Practice Address - Phone:516-350-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112714-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical