Healthcare Provider Details

I. General information

NPI: 1861550105
Provider Name (Legal Business Name): LINDA LAFATA CONNOLLY PHD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 VINE ST
PASO ROBLES CA
93446-2559
US

IV. Provider business mailing address

PO BOX 1631
SAN LUIS OBISPO CA
93406-1631
US

V. Phone/Fax

Practice location:
  • Phone: 805-237-3170
  • Fax: 805-226-3107
Mailing address:
  • Phone: 805-471-5723
  • Fax: 805-771-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 36940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: