Provider Demographics
NPI:1952572620
Name:CONNELLY, LISA DIANNE (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33444 N KARI RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3073
Mailing Address - Country:US
Mailing Address - Phone:480-495-5356
Mailing Address - Fax:
Practice Address - Street 1:7254 E SOUTHERN AVE
Practice Address - Street 2:SUITE 123
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2786
Practice Address - Country:US
Practice Address - Phone:480-495-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC12225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional