Provider Demographics
NPI:1164763363
Name:O'CONNOR, DAWN MARIE (MA, MS, LLP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:MA, MS, LLP
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:KRULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, MS, LLP
Mailing Address - Street 1:23231 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1361
Mailing Address - Country:US
Mailing Address - Phone:248-581-8777
Mailing Address - Fax:
Practice Address - Street 1:23231 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1361
Practice Address - Country:US
Practice Address - Phone:248-581-8777
Practice Address - Fax:888-975-9374
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007574103T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164763363Medicaid