MEDICARE: KATHLEEN MARY 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
1	1041C0700X	Clinical Social Worker	150.111073	IL

General Provider Information

NPI Number	:	1609634344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARY CONNELLY

Provider Business Mailing Address
First Line	:	12305 W BRUNS RD
Second Line	:
City	:	MANHATTAN
State	:	IL
Zip	:	60442-9201
Country	:	US
Telephone Number	:	708-674-4940
Fax Number	:

Provider Business Practice Location Address
First Line	:	265 STEBBINGS CT STE 1
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1282
Country	:	US
Telephone Number	:	815-944-2753
Fax Number	:

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

Provider Enumeration Date	:	03/07/2024
Last Update Date	:	03/07/2024

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Directions to “ KATHLEEN MARY CONNELLY ” Practice Location

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