Healthcare Provider Details

I. General information

NPI: 1205817541
Provider Name (Legal Business Name): CONNIE JEAN POLLOCK L,I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MRS. CONNIE JEAN BAYNARD

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 OLD TROY PIKE
DAYTON OH
45424-5740
US

IV. Provider business mailing address

2197 KYLE LN
FAIRBORN OH
45324-6418
US

V. Phone/Fax

Practice location:
  • Phone: 937-233-1230
  • Fax: 937-236-8930
Mailing address:
  • Phone: 937-236-8920
  • Fax: 937-236-8930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0007011
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: