Healthcare Provider Details

I. General information

NPI: 1801045992
Provider Name (Legal Business Name): DENISE MARIE CONNELLY LCSW-C; CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 BUCKEYSTOWN PIKE SUITE170
FREDERICK MD
21704-8370
US

IV. Provider business mailing address

13218 BROOKLANE DR
HAGERSTOWN MD
21742-1435
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0330
  • Fax: 301-733-4038
Mailing address:
  • Phone: 301-733-0330
  • Fax: 301-733-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC0669
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: