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General NPI Number Information
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NPI Number | 1467930453
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Entity Type | Organization
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Legal Business Name | SUSAN CONNELLY LICENSED CLINICAL SOCIAL WORKER, P.C.
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Dates
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Enumeration Date | 08/01/2018
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Last Update Date | 04/23/2020
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Provider Practice Location Address
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Address Line | 515 E. MAIN ST
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City | ENDICOTT
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State | NY
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Zip | 13760-5023
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Country | US
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Telephone | 607-427-4430
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Fax | 607-444-3319
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Provider Business Mailing Address
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Address Line | 515 E MAIN ST
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City | ENDICOTT
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State | NY
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Zip | 13760-5023
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Country | US
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Telephone | 607-427-4430
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Fax | 607-444-3319
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | SUSAN L CONNELLY
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Credential | LCSW
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Telephone | 607-427-4430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 043911-1
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License Number State | NY
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