Provider Demographics
NPI:1215754023
Name:CONNOLLY, KEVIN JAMES (LMSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 48TH ST UNIT 2F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1524
Mailing Address - Country:US
Mailing Address - Phone:908-403-8726
Mailing Address - Fax:
Practice Address - Street 1:57 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4038
Practice Address - Country:US
Practice Address - Phone:718-716-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124176104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker