Provider Demographics
NPI:1952424616
Name:CONNOLLY, MICHAEL CHARLES (LMHC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 PIPER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4320
Mailing Address - Country:US
Mailing Address - Phone:904-287-1261
Mailing Address - Fax:
Practice Address - Street 1:3947 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6115
Practice Address - Country:US
Practice Address - Phone:904-234-7803
Practice Address - Fax:904-899-8759
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health