Healthcare Provider Details

I. General information

NPI: 1629779798
Provider Name (Legal Business Name): JOSEPH LARRY CONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 W MARKET ST # 5
AKRON OH
44303-1009
US

IV. Provider business mailing address

1136 COPLEY RD APT 2
AKRON OH
44320-2772
US

V. Phone/Fax

Practice location:
  • Phone: 240-432-7659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: