Healthcare Provider Details

I. General information

NPI: 1689356628
Provider Name (Legal Business Name): GINA CONNOLLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WHITNEY AVE
HAMDEN CT
06517-2499
US

IV. Provider business mailing address

1400 WHITNEY AVE
HAMDEN CT
06517-2499
US

V. Phone/Fax

Practice location:
  • Phone: 203-248-2116
  • Fax: 203-248-2572
Mailing address:
  • Phone: 203-248-2116
  • Fax: 203-248-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number012634
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: