Provider Demographics
NPI:1912916321
Name:O'CONNOR, COLLEEN M (LCSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY STE 160
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2782
Mailing Address - Country:US
Mailing Address - Phone:207-553-6700
Mailing Address - Fax:207-553-6730
Practice Address - Street 1:195 FORE RIVER PKWY STE 160
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2782
Practice Address - Country:US
Practice Address - Phone:207-553-6700
Practice Address - Fax:207-553-6730
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC9899104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME404880099Medicaid