Provider Demographics
NPI:1700326782
Name:MCCONNICO, TYRONE JEROME (LCSW)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:JEROME
Last Name:MCCONNICO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4393
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06147-4393
Mailing Address - Country:US
Mailing Address - Phone:860-985-2627
Mailing Address - Fax:
Practice Address - Street 1:196 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-2407
Practice Address - Country:US
Practice Address - Phone:860-985-2627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009688104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009688OtherLICENSE