Provider Demographics
NPI:1700923448
Name:CONNOLLY, LESLIE B (LCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HUNTS POINT RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-2926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MIDDLE ST
Practice Address - Street 2:5
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4869
Practice Address - Country:US
Practice Address - Phone:207-831-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC108771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME274500099Medicaid