Provider Demographics
NPI:1770833139
Name:O'CONNOR, LISA MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 RULANE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-9999
Mailing Address - Country:US
Mailing Address - Phone:608-669-6609
Mailing Address - Fax:
Practice Address - Street 1:1604 RULANE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-9999
Practice Address - Country:US
Practice Address - Phone:608-669-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1041C0700X
WI128794-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker