Basic Information
| Provider Information | |||||||||
| NPI: | 1275016255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNORS | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 8662772034 | ||||||||
| Practice Location | |||||||||
| Address1: | 9220 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 8662772034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | S.1101551 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2864093 | 05 | OH | MEDICAID |