Provider Demographics
NPI:1922101419
Name:O'CONNOR, SHELLEY ANN (LCSW, MS)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LCSW, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 212TH ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1440
Mailing Address - Country:US
Mailing Address - Phone:410-508-1580
Mailing Address - Fax:877-258-9432
Practice Address - Street 1:458 RITCHIE HIGHWAY
Practice Address - Street 2:SUITE 203D
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:410-508-1580
Practice Address - Fax:877-258-9432
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0153941041C0700X
MD207481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD485251Medicare PIN