Provider Demographics
NPI:1700957081
Name:O'CONNOR, EDMUND ANTHONY JR (LP)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:ANTHONY
Last Name:O'CONNOR
Suffix:JR
Gender:M
Credentials:LP
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Mailing Address - Street 1:1438 EASTLAWN RD SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4108
Mailing Address - Country:US
Mailing Address - Phone:616-328-3686
Mailing Address - Fax:
Practice Address - Street 1:330 BILLINGSLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5055
Practice Address - Country:US
Practice Address - Phone:704-512-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301011402103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1700957081Medicaid