Provider Demographics
NPI:1295233922
Name:CONNELLY, CAITLIN T
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:T
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 1:800 WILSON AVE RM 330
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2746
Mailing Address - Country:US
Mailing Address - Phone:715-256-7166
Mailing Address - Fax:888-427-8048
Practice Address - Street 1:800 WILSON AVE RM 330
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2746
Practice Address - Country:US
Practice Address - Phone:715-256-7166
Practice Address - Fax:888-427-8048
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7726-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional