=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386114197
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY LYNN CONNEELY LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2018
-----------------------------------------------------
Last Update Date | 12/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3680 WARWICK RD
-----------------------------------------------------
City | EAST NEW MARKET
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21631-1420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-943-1722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26331 HOBBS RD
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21629-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19152
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------