Healthcare Provider Details

I. General information

NPI: 1043204563
Provider Name (Legal Business Name): BONNIE L CONNOLLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 1/2 W GENEVA ST CREDENCE THERAPY ASSOCIATES
ELKHORN WI
53121-1722
US

IV. Provider business mailing address

1 1/2 W GENEVA ST CREDENCE THERAPY ASSOCIATES
ELKHORN WI
53121-1722
US

V. Phone/Fax

Practice location:
  • Phone: 262-723-3424
  • Fax: 262-723-8308
Mailing address:
  • Phone: 262-723-3424
  • Fax: 262-723-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLI2718125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: