1336487438 NPI number — MS. MARY KIMBERLY O'CONNOR LCSW-R

Table of content: MS. MARY KIMBERLY O'CONNOR LCSW-R (NPI 1336487438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336487438 NPI number — MS. MARY KIMBERLY O'CONNOR LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'CONNOR
Provider First Name:
MARY
Provider Middle Name:
KIMBERLY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW-R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336487438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 SONN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RYE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10580-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-453-2328
Provider Business Mailing Address Fax Number:
914-925-9839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 ELM PL STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RYE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10580-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-453-2328
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R048401-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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