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General NPI Number Information
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NPI Number | 1609634344
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Entity Type | Individual
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Provider Name | KATHLEEN MARY CONNELLY
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Gender | Female
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Dates
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Enumeration Date | 03/07/2024
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 265 STEBBINGS CT STE 1
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City | BRADLEY
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State | IL
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Zip | 60915-1282
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Country | US
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Telephone | 815-944-2753
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Fax |
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Provider Business Mailing Address
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Address Line | 12305 W BRUNS RD
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City | MANHATTAN
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State | IL
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Zip | 60442-9201
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Country | US
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Telephone | 708-674-4940
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 150.111073
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License Number State | IL
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