Healthcare Provider Details

I. General information

NPI: 1366877391
Provider Name (Legal Business Name): KATHRYN CONLEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 HARRISON AVE STE G104-7
MAMARONECK NY
10543-3145
US

IV. Provider business mailing address

7 FERN RD
LARCHMONT NY
10538-1501
US

V. Phone/Fax

Practice location:
  • Phone: 949-521-0366
  • Fax:
Mailing address:
  • Phone: 949-521-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number020254
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number020254
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number020254
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: