Provider Demographics
NPI:1548719966
Name:CONNELLY, DINA LEE (LISW-CP)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:LEE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:DINA
Other - Middle Name:LEE
Other - Last Name:SITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-CP
Mailing Address - Street 1:3050 MACK RD STE 205
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5376
Mailing Address - Country:US
Mailing Address - Phone:513-682-6980
Mailing Address - Fax:513-981-5783
Practice Address - Street 1:3050 MACK RD STE 205
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5376
Practice Address - Country:US
Practice Address - Phone:513-682-6980
Practice Address - Fax:513-981-5783
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH30647671041S0200X
SC129351041C0700X
OHI.1303609-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12935OtherSC MEDICAL LICENSE
OHI.1303609.SUPVOtherLISW-S