MEDICARE: CONNALLY COUNSELING

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	1041C0700X	Clinical Social Worker	6801095252	MI

General Provider Information

NPI Number	:	1598193310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNALLY COUNSELING

Provider Business Mailing Address
First Line	:	3300 WASHTENAW AVE STE 260
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5184
Country	:	US
Telephone Number	:	734-277-7565
Fax Number	:	734-215-2363

Provider Business Practice Location Address
First Line	:	3300 WASHTENAW AVE STE 260
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5184
Country	:	US
Telephone Number	:	734-277-7565
Fax Number	:	734-215-2363

Authorized Official
Title or Position	:	OWNER
Name	:	DALTON KILLIAN CONNALLY
Credential	:	PHD
Telephone Number	:	517-676-9788

Provider Enumeration Date	:	10/15/2013
Last Update Date	:	08/05/2021

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