Basic Information
| Provider Information | |||||||||
| NPI: | 1932676608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNOR | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | MA, LCMHC, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3710 UNIVERSITY DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199064390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3710 UNIVERSITY DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199064390 | ||||||||
| FaxNumber: | 8285441201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 21098 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LPC010427 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LPC.0014070 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 15233 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.