Basic Information
| Provider Information | |||||||||
| NPI: | 1386286896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNOR | ||||||||
| FirstName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 TREMONT RD | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117571734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163613576 | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 GRAND BLVD STE 17 | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117295725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163613576 | ||||||||
| FaxNumber: | 6313924358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2019 | ||||||||
| LastUpdateDate: | 10/16/2019 | ||||||||
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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 | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.