MEDICARE: DR. MEDRIA LOU CONNOLLY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY9977	CA
2	103TC2200X	Clinical Child & Adolescent Psychologist	PSY9977	CA
3	103T00000X	Psychologist	PSY9977	CA

General Provider Information

NPI Number	:	1164540316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MEDRIA LOU CONNOLLY PH.D.

Provider Business Mailing Address
First Line	:	2444 WILSHIRE BLVD
Second Line	:	SUITE 500
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5808
Country	:	US
Telephone Number	:	310-264-2602
Fax Number	:	310-264-2601

Provider Business Practice Location Address
First Line	:	2444 WILSHIRE BLVD
Second Line	:	SUITE 500
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5808
Country	:	US
Telephone Number	:	310-264-2602
Fax Number	:	310-264-2601

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	09/11/2025

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