Provider Demographics
NPI:1760955322
Name:O'CONNOR, MERCEDIES-MARIE MIKALA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MERCEDIES-MARIE
Middle Name:MIKALA
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:MERCEDIES-MARIE
Other - Middle Name:MIKALA
Other - Last Name:MCCALLA-SIMMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA, LBA
Mailing Address - Street 1:2 VILLAGE SQ STE 210
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:609-525-4271
Mailing Address - Fax:443-743-3863
Practice Address - Street 1:14059 CROWN CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1458
Practice Address - Country:US
Practice Address - Phone:866-565-7222
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-22-58192103K00000X
VA0133002457103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1760955322Medicaid