Provider Demographics
NPI:1811004286
Name:O'CONNOR, CONNIE M
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:M
Last Name:O'CONNOR
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 1:1959 NE PACIFIC ST
Mailing Address - Street 2:C212, BOX 356340
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:C212, BOX 356340
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6340
Practice Address - Country:US
Practice Address - Phone:206-543-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000449292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000917190OtherBLUE CROSS-SHIELD OF MONTANA CENTER FOR MENTAL HEALTH
MTP01205491 C01340OtherRAILROAD MEDICARE FOR C4MH
MT0000917190OtherBLUE CROSS-SHIELD OF MONTANA CENTER FOR MENTAL HEALTH