Basic Information
| Provider Information | |||||||||
| NPI: | 1407838758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKESDALE AVE SW | ||||||||
| Address2: | STE 104 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252285336 | ||||||||
| FaxNumber: | 4252284540 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 OAKESDALE AVE SW | ||||||||
| Address2: | STE 104 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252285336 | ||||||||
| FaxNumber: | 4252284540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY00001058 | WA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000106440 | 05 | WA | MEDICAID |