Provider Demographics
NPI:1023066214
Name:CONNOLLY, AMY MICHELLE (LPC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:4300 NE FREMONT ST STE 260
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1100
Mailing Address - Country:US
Mailing Address - Phone:503-866-3971
Mailing Address - Fax:
Practice Address - Street 1:4300 NE FREMONT ST STE 260
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1100
Practice Address - Country:US
Practice Address - Phone:503-866-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1676101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional