Provider Demographics
NPI:1396042297
Name:CONNOLLY, ROBERT LEO (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEO
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 HUNTINGTON DR
Mailing Address - Street 2:SUITE #301
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4552
Mailing Address - Country:US
Mailing Address - Phone:626-768-1083
Mailing Address - Fax:
Practice Address - Street 1:1499 HUNTINGTON DR
Practice Address - Street 2:SUITE #301
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4552
Practice Address - Country:US
Practice Address - Phone:626-768-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-12
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23835103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical