Provider Demographics
NPI:1255613626
Name:O'CONNOR, KERRY ANNE
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:ANNE
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 1:1301 W COSSITT AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2145
Mailing Address - Country:US
Mailing Address - Phone:708-783-4320
Mailing Address - Fax:
Practice Address - Street 1:1301 W COSSITT AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2145
Practice Address - Country:US
Practice Address - Phone:708-783-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-09-5178103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst