Healthcare Provider Details

I. General information

NPI: 1669815288
Provider Name (Legal Business Name): DALTON KILLIAN CONNALLY LMSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WASHTENAW AVE STE 260
ANN ARBOR MI
48104-5184
US

IV. Provider business mailing address

3300 WASHTENAW AVE STE 260
ANN ARBOR MI
48104-5184
US

V. Phone/Fax

Practice location:
  • Phone: 734-277-7565
  • Fax: 734-215-2363
Mailing address:
  • Phone: 734-277-7565
  • Fax: 734-215-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095252
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: