Healthcare Provider Details

I. General information

NPI: 1578262259
Provider Name (Legal Business Name): TREVAR CONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 6TH ST
CLARKSTON WA
99403-2079
US

IV. Provider business mailing address

920 6TH ST
CLARKSTON WA
99403-2079
US

V. Phone/Fax

Practice location:
  • Phone: 509-254-5053
  • Fax: 509-769-3500
Mailing address:
  • Phone: 208-982-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC.LH.70069124
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6671759
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: