Provider Demographics
NPI:1356393052
Name:CONNELLY, KARIN (PHD)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-5149
Mailing Address - Country:US
Mailing Address - Phone:845-750-0476
Mailing Address - Fax:845-336-4014
Practice Address - Street 1:1 COMMONS DR
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5149
Practice Address - Country:US
Practice Address - Phone:845-750-0476
Practice Address - Fax:845-336-4014
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012496103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354316Medicaid