Provider Demographics
NPI:1861254112
Name:CONERLY, CULLEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CULLEN
Middle Name:
Last Name:CONERLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 E MISSOURI AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2726
Mailing Address - Country:US
Mailing Address - Phone:423-505-8885
Mailing Address - Fax:
Practice Address - Street 1:1130 E MISSOURI AVE STE 800
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2726
Practice Address - Country:US
Practice Address - Phone:423-505-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical