Provider Demographics
NPI:1982057675
Name:O'CONNOR, LAURA LEE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PROSPECT AVE SE
Mailing Address - Street 2:APT 1
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4343
Mailing Address - Country:US
Mailing Address - Phone:269-861-3414
Mailing Address - Fax:
Practice Address - Street 1:124 PROSPECT AVE SE
Practice Address - Street 2:APT 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4343
Practice Address - Country:US
Practice Address - Phone:269-861-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician