Healthcare Provider Details

I. General information

NPI: 1740293505
Provider Name (Legal Business Name): LYNETTE R CONNELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E MAIN ST
WESTMINSTER MD
21157-5355
US

IV. Provider business mailing address

4623 FALLS RD
BALTIMORE MD
21209-4914
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-7830
  • Fax: 410-876-4791
Mailing address:
  • Phone: 410-366-1980
  • Fax: 410-366-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06613
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: