Provider Demographics
NPI:1700635315
Name:CONNOLLY, KATHRYN MARY (AMFT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 RUNNING CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5453
Mailing Address - Country:US
Mailing Address - Phone:805-501-6157
Mailing Address - Fax:
Practice Address - Street 1:325 E HILLCREST DR STE 115
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7782
Practice Address - Country:US
Practice Address - Phone:805-601-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health