Provider Demographics
NPI:1770247280
Name:CONNER, MARIE LISE LINDA (LPCA)
Entity type:Individual
Prefix:MS
First Name:MARIE LISE
Middle Name:LINDA
Last Name:CONNER
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5031
Mailing Address - Country:US
Mailing Address - Phone:859-457-3082
Mailing Address - Fax:
Practice Address - Street 1:110 YE OLDE KINGS HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4384
Practice Address - Country:US
Practice Address - Phone:843-663-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health