Provider Demographics
NPI:1912471103
Name:CONNELLY, TAMARA (CCS SERVICE FACILITA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:CCS SERVICE FACILITA
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:UFKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:727 8TH ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1794
Mailing Address - Country:US
Mailing Address - Phone:414-305-2574
Mailing Address - Fax:
Practice Address - Street 1:727 8TH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1794
Practice Address - Country:US
Practice Address - Phone:414-305-2574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator