Healthcare Provider Details

I. General information

NPI: 1033189550
Provider Name (Legal Business Name): LOREN CONNOLLY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD REHAB DEPARTMENT
BALTIMORE MD
21239-2945
US

IV. Provider business mailing address

501 LOCH RAVEN BLVD.
BALTIMORE MD
21239
US

V. Phone/Fax

Practice location:
  • Phone: 443-444-4034
  • Fax:
Mailing address:
  • Phone: 443-444-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberB10000554
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number05866
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: