Provider Demographics
NPI:1841756327
Name:CONNOR, MCDERMOTT WILTON (MA, LCMHCA, LCASA)
Entity Type:Individual
Prefix:
First Name:MCDERMOTT
Middle Name:WILTON
Last Name:CONNOR
Suffix:
Gender:M
Credentials:MA, LCMHCA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1352
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-1352
Mailing Address - Country:US
Mailing Address - Phone:980-330-8470
Mailing Address - Fax:
Practice Address - Street 1:4922 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6618
Practice Address - Country:US
Practice Address - Phone:704-510-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25057101YA0400X
101YM0800X
NCA14619101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health