Basic Information
| Provider Information | |||||||||
| NPI: | 1215141437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | SANDERS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDERS | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | AMELIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 351 | ||||||||
| Address2: | |||||||||
| City: | BALTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063300351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038158725 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1320 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062261940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 017131 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 003015 | CT | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.