Provider Demographics
NPI:1588228290
Name:O'CONNOR, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9019
Mailing Address - Country:US
Mailing Address - Phone:304-651-5021
Mailing Address - Fax:
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758-9019
Practice Address - Country:US
Practice Address - Phone:304-651-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170338101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)