Provider Demographics
NPI:1750387577
Name:CONNELL, DAVID K (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:K
Last Name:CONNELL
Suffix:
Gender:M
Credentials:PHD
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 8440
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-0440
Mailing Address - Country:US
Mailing Address - Phone:419-788-7019
Mailing Address - Fax:
Practice Address - Street 1:1011 N BYRNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-2710
Practice Address - Country:US
Practice Address - Phone:419-788-7019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4675103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2332676Medicaid
OH463779000OtherMAGELLAN
OH000000503824OtherANTHEM BC
OH5692018OtherAETNA
OH291267OtherTRICARE CHAMPUS
OHP00322126OtherRR MEDICARE
OH463779000OtherMAGELLAN
OHP00322126OtherRR MEDICARE