Provider Demographics
NPI:1780448514
Name:CONNOLLY, VICTORIA L (LPATA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LPATA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BRECKENRIDGE LN STE 114
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3868
Mailing Address - Country:US
Mailing Address - Phone:502-653-7211
Mailing Address - Fax:502-416-0723
Practice Address - Street 1:3027 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1716
Practice Address - Country:US
Practice Address - Phone:502-653-7211
Practice Address - Fax:502-416-0723
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X
KY271289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist