Provider Demographics
NPI:1164853818
Name:O'CONNOR, KELLY (MSSA, LISW-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:MSSA, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4389 SILSBY RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3963
Mailing Address - Country:US
Mailing Address - Phone:216-401-7791
Mailing Address - Fax:
Practice Address - Street 1:4389 SILSBY RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3963
Practice Address - Country:US
Practice Address - Phone:216-401-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1100153-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical