1740293505 NPI number — LYNETTE R CONNELLY LCSW

Table of content: LYNETTE R CONNELLY LCSW (NPI 1740293505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740293505 NPI number — LYNETTE R CONNELLY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNELLY
Provider First Name:
LYNETTE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740293505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4623 FALLS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21209-4914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-366-1980
Provider Business Mailing Address Fax Number:
410-366-8530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21157-5355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-848-7830
Provider Business Practice Location Address Fax Number:
410-876-4791
Provider Enumeration Date:
08/14/2006

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:  06613 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 396957 . This is a "TRICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 298638-000 . This is a "MAGELLAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7983549 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 038119 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 231252 . This is a "COMPSYCH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 257613 . This is a "KAISER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 284441 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 530200500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2321497000 . This is a "AMERIHEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 248514 . This is a "UNITED BEHAVORIAL HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 887526-01 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: T541-0004 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: PVPB213077 . This is a "APS HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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