Provider Demographics
NPI:1629388202
Name:OCONNOR, THERESA ROSE (PPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ROSE
Last Name:OCONNOR
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5446 W KATHLEEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2712
Mailing Address - Country:US
Mailing Address - Phone:801-859-9798
Mailing Address - Fax:
Practice Address - Street 1:350 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2266
Practice Address - Country:US
Practice Address - Phone:385-246-3349
Practice Address - Fax:801-322-4002
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT8634614-6004101YP2500X
ORC5932101YP2500X
UT6681105171M00000X
UT8634614-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator