Provider Demographics
NPI:1992876064
Name:CONNELLY, TERESA JOSEPHINE (MA)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:JOSEPHINE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
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Mailing Address - Street 1:277 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5843
Mailing Address - Country:US
Mailing Address - Phone:763-717-4979
Mailing Address - Fax:763-717-4954
Practice Address - Street 1:1874 3RD ST SW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:763-717-4979
Practice Address - Fax:763-717-4954
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP2332103TA0400X, 103TB0200X, 103TF0000X, 103TP2701X, 106H00000X, 103TC0700X, 101YM0800X, 103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57348COOtherBLUECROSS PROVIDER NUMBER