Provider Demographics
NPI:1679602205
Name:CONNELL, ANDREA E (LISW-S)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:CONNELL
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 DAWNLIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1934
Mailing Address - Country:US
Mailing Address - Phone:614-471-2626
Mailing Address - Fax:
Practice Address - Street 1:2440 DAWNLIGHT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1934
Practice Address - Country:US
Practice Address - Phone:614-471-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0600588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicare UPIN