Healthcare Provider Details

I. General information

NPI: 1548665052
Provider Name (Legal Business Name): MICHAEL CONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 MAIN ST
NEW BRITAIN CT
06051-4204
US

IV. Provider business mailing address

85 PINE BROOK TER APT 2
BRISTOL CT
06010-7428
US

V. Phone/Fax

Practice location:
  • Phone: 617-459-5519
  • Fax:
Mailing address:
  • Phone: 617-459-5519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3756
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number46.003756
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: