Basic Information
Provider Information | |||||||||
NPI: | 1891020418 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONNOLLY-RENSHAW | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | MOORE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2336 GODDARD PKWY | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218011126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: | 4103346960 | ||||||||
Practice Location | |||||||||
Address1: | 29516 CANVASBACK DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216017140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108225007 | ||||||||
FaxNumber: | 4108225569 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2009 | ||||||||
LastUpdateDate: | 10/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 609500300 | 05 | MD |   | MEDICAID | 609550004 | 05 | MD |   | MEDICAID | 609500303 | 05 | MD |   | MEDICAID | 609550001 | 05 | MD |   | MEDICAID | 609550002 | 05 | MD |   | MEDICAID |