Provider Demographics
NPI:1124155726
Name:O'CONNOR, TIMOTHY J (LCSW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 N STATE ROAD 7 BLDG B
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5860
Mailing Address - Country:US
Mailing Address - Phone:954-497-3850
Mailing Address - Fax:954-497-3857
Practice Address - Street 1:4720 N STATE ROAD 7 BLDG B
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5860
Practice Address - Country:US
Practice Address - Phone:954-497-3850
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW56221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL763866300Medicaid