Provider Demographics
NPI:1477633378
Name:CONNOR, PAUL D (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:CONNOR
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 1:22517 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6820
Mailing Address - Country:US
Mailing Address - Phone:206-940-1106
Mailing Address - Fax:206-870-9081
Practice Address - Street 1:22517 7TH AVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6820
Practice Address - Country:US
Practice Address - Phone:206-940-1106
Practice Address - Fax:206-870-9081
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002050103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
4323OtherINTERNAL ID-MOTOR VEHICLE ID
WA7144058Medicaid
4323OtherINTERNAL ID-MOTOR VEHICLE ID
8858622Medicare ID - Type Unspecified