Provider Demographics
NPI:1235291469
Name:O'CONNOR, KEVIN ROBERT (MFT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ROBERT
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MEADOWLAND DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-9512
Mailing Address - Country:US
Mailing Address - Phone:209-599-5535
Mailing Address - Fax:209-599-5535
Practice Address - Street 1:965 E YOSEMITE AVE
Practice Address - Street 2:SUITE # 12
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5938
Practice Address - Country:US
Practice Address - Phone:209-404-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41168106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist