MEDICARE: DR. KEVIN J CONNOLLY PH.D.

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
1	103TC0700X	Clinical Psychologist	001144	CT

General Provider Information

NPI Number	:	1336246925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN J CONNOLLY PH.D.

Provider Business Mailing Address
First Line	:	34 JEROME AVE
Second Line	:	SUITE 301
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2463
Country	:	US
Telephone Number	:	860-242-3702
Fax Number	:	860-242-1964

Provider Business Practice Location Address
First Line	:	34 JEROME AVE
Second Line	:	SUITE 301
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2463
Country	:	US
Telephone Number	:	860-242-3702
Fax Number	:	860-242-1964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	12/26/2024

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