Healthcare Provider Details

I. General information

NPI: 1760397954
Provider Name (Legal Business Name): SUSAN CONNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 W NORTHERN AVE
PHOENIX AZ
85021-5157
US

IV. Provider business mailing address

6165 W FLOWER ST
PHOENIX AZ
85033-5318
US

V. Phone/Fax

Practice location:
  • Phone: 623-707-6492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: