Provider Demographics
NPI:1396133757
Name:CONNELLY, ELIZABETH (PC)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2658
Mailing Address - Country:US
Mailing Address - Phone:937-426-2686
Mailing Address - Fax:937-426-6230
Practice Address - Street 1:1411 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2658
Practice Address - Country:US
Practice Address - Phone:937-426-2686
Practice Address - Fax:937-426-6230
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1400542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional