Provider Demographics
NPI:1841324332
Name:CONNELLY, JAMES WILLIAM (PSYD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13389 W BELLFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1345
Mailing Address - Country:US
Mailing Address - Phone:208-939-0951
Mailing Address - Fax:
Practice Address - Street 1:2076 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:208-955-7330
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 202425103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002269500Medicaid