Provider Demographics
NPI:1215299250
Name:CONNELL, ERIN KELLY (MS)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:KELLY
Last Name:CONNELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 FORDHAM AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3132
Mailing Address - Country:US
Mailing Address - Phone:631-617-3583
Mailing Address - Fax:
Practice Address - Street 1:164 FORDHAM AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3132
Practice Address - Country:US
Practice Address - Phone:631-617-3583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
NY000311-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist