Provider Demographics
NPI:1669897443
Name:CATHY SUPON CONNOR LLC
Entity type:Organization
Organization Name:CATHY SUPON CONNOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:SUPON
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-381-1520
Mailing Address - Street 1:429 S TYNDALL PKWY STE G
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6746
Mailing Address - Country:US
Mailing Address - Phone:850-381-3701
Mailing Address - Fax:
Practice Address - Street 1:429 S TYNDALL PKWY STE G
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6746
Practice Address - Country:US
Practice Address - Phone:850-381-3701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW88921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL769063100Medicaid
D0095ZMedicare PIN