Provider Demographics
NPI:1124145776
Name:CONNELLY, REBECCA J (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:J
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 HITCHING POST PL
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8990
Mailing Address - Country:US
Mailing Address - Phone:859-322-4346
Mailing Address - Fax:859-488-3038
Practice Address - Street 1:116 HITCHING POST PL
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-8990
Practice Address - Country:US
Practice Address - Phone:859-322-4346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1469235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-1469OtherSTATE LICENSE NUMBER