Provider Demographics
NPI:1023372091
Name:CONNELLY, ROSEANN (MA TSHH)
Entity type:Individual
Prefix:MS
First Name:ROSEANN
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:MA TSHH
Other - Prefix:
Other - First Name:ROSEANN
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, TSHH
Mailing Address - Street 1:666 SHORE RD APT 4J
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4616
Mailing Address - Country:US
Mailing Address - Phone:516-260-3436
Mailing Address - Fax:516-992-0878
Practice Address - Street 1:666 SHORE RD APT 4J
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4616
Practice Address - Country:US
Practice Address - Phone:516-260-3436
Practice Address - Fax:516-992-0878
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 2355S0801X
NY17012052355S0801X
NY657266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty