Basic Information
| Provider Information | |||||||||
| NPI: | 1619273935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNOR | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 LONGLEAF CT | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301141701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784519833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787514519 | ||||||||
| FaxNumber: | 4787514530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2011 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 003521 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 003521 | 01 | GA | LPC | OTHER |