1508168386 NPI number — CIRSTIN CONNEELY

Table of content: CIRSTIN CONNEELY (NPI 1508168386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508168386 NPI number — CIRSTIN CONNEELY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNEELY
Provider First Name:
CIRSTIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNORS
Provider Other First Name:
CIRSTIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508168386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 EASTERN PKWY
Provider Second Line Business Mailing Address:
APT. 3A
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11238-5939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-622-0469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 PLAZA ST E
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11238-5038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-536-6040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  73 076706 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)