Provider Demographics
NPI:1285953091
Name:CONNELLA, MICHAEL E
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CONNELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10756 E FAWN LN
Mailing Address - Street 2:
Mailing Address - City:TALALA
Mailing Address - State:OK
Mailing Address - Zip Code:74080-9444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10756 E FAWN LN
Practice Address - Street 2:
Practice Address - City:TALALA
Practice Address - State:OK
Practice Address - Zip Code:74080-9444
Practice Address - Country:US
Practice Address - Phone:918-261-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor