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General NPI Number Information
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NPI Number | 1285109801
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Entity Type | Individual
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Provider Name | JUSTIN MICHAEL CONNELLY
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Gender | Male
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Dates
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Enumeration Date | 10/10/2018
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 305 E JEFFERSON ST
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City | BOISE
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State | ID
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Zip | 83712-6231
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Country | US
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Telephone | 208-381-5000
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Fax | 208-381-5005
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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