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General NPI Number Information
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NPI Number | 1437519352
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Entity Type | Organization
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Legal Business Name | MICHAEL C CONNOLLY
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Dates
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Enumeration Date | 03/04/2016
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Last Update Date | 03/04/2016
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Provider Practice Location Address
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Address Line | 8825 PERIMETER PARK BLVD STE 602
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City | JACKSONVILLE
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State | FL
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Zip | 32216-1122
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Country | US
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Telephone | 904-234-7803
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Fax |
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Provider Business Mailing Address
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Address Line | 412 PIPER PL
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City | SAINT JOHNS
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State | FL
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Zip | 32259-4320
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Country | US
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Telephone | 904-234-7803
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICIAN
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Name | MICHAEL CONNOLLY
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Credential | LMHC
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Telephone | 904-234-7803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH 4717
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License Number State | FL
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