Provider Demographics
NPI:1174575385
Name:CONNOLLY-NELSON LISW, SUSAN (LISW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CONNOLLY-NELSON LISW
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 CALHOUN STREET, NUMBER 8 RAINBOW ROW,
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-256-9700
Mailing Address - Fax:803-256-2519
Practice Address - Street 1:1898 CALHOUN STREET, NUMBER 8 RAINBOW ROW,
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-256-9700
Practice Address - Fax:803-256-2519
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical