Provider Demographics
NPI:1952970691
Name:CONNER, HENRY L
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:L
Last Name:CONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 GOLD CUP CT
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-6381
Mailing Address - Country:US
Mailing Address - Phone:910-381-7668
Mailing Address - Fax:
Practice Address - Street 1:5605 GOLD CUP CT
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-6381
Practice Address - Country:US
Practice Address - Phone:910-381-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL150241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical