Provider Demographics
NPI:1518748839
Name:OCONNOR, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OCONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 CROSS BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:BROAD CHANNEL
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1027
Mailing Address - Country:US
Mailing Address - Phone:917-883-4607
Mailing Address - Fax:
Practice Address - Street 1:422 CROSS BAY BLVD
Practice Address - Street 2:
Practice Address - City:BROAD CHANNEL
Practice Address - State:NY
Practice Address - Zip Code:11693-1027
Practice Address - Country:US
Practice Address - Phone:917-833-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002496-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant