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NPI Code Detail

MEDICARE: AMANDA GRACE CONNELLY

MEDICARE: AMANDA GRACE CONNELLY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor9785NC

General Provider Information

NPI Number : 1013170885
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA GRACE CONNELLY
Provider Business Mailing Address
First Line : 350 PEE DEE AVE STE 101
Second Line :
City : ALBEMARLE
State : NC
Zip : 28001-4945
Country : US
Telephone Number : 704-986-1500
Fax Number :
Provider Business Practice Location Address
First Line : 4140 CHERRY ST
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27105-2536
Country : US
Telephone Number : 336-306-9620
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/02/2008
Last Update Date : 12/01/2017

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Directions to “ AMANDA GRACE CONNELLY ” Practice Location

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