Provider Demographics
NPI:1265926893
Name:KATI CONNELLY PHD PLLC
Entity type:Organization
Organization Name:KATI CONNELLY PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR, STOCKHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HSP-P
Authorized Official - Phone:703-477-4969
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-0219
Mailing Address - Country:US
Mailing Address - Phone:703-477-4969
Mailing Address - Fax:
Practice Address - Street 1:895 STATE FARM RD STE 504
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4689
Practice Address - Country:US
Practice Address - Phone:703-477-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5050103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306386677OtherNPPES