Provider Demographics
NPI:1134250152
Name:O'CONNOR, ROBERT EDWARD (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1024
Mailing Address - Country:US
Mailing Address - Phone:708-366-5699
Mailing Address - Fax:
Practice Address - Street 1:1103 WESTGATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1088
Practice Address - Country:US
Practice Address - Phone:708-386-1761
Practice Address - Fax:708-383-4298
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL 7103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL981500Medicare UPIN