Provider Demographics
NPI:1447321492
Name:CONNOLLY, SEAN GERARD (PHD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:GERARD
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD.,
Mailing Address - Street 2:SUITE 298 WEST
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213
Mailing Address - Country:US
Mailing Address - Phone:210-737-2039
Mailing Address - Fax:210-737-1396
Practice Address - Street 1:6800 PARK TEN BLVD.,
Practice Address - Street 2:SUITE 298 WEST
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213
Practice Address - Country:US
Practice Address - Phone:210-737-2039
Practice Address - Fax:210-737-1396
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21215103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00NC54Medicare ID - Type UnspecifiedPROVIDER ID