Provider Demographics
NPI:1972909463
Name:O'CONNOR, TIMOTHY P (BA,CAC I I)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:BA,CAC I I
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:OCONNOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA,CAC II
Mailing Address - Street 1:3065 MOUNT HERMAN RD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8196
Mailing Address - Country:US
Mailing Address - Phone:719-322-7175
Mailing Address - Fax:
Practice Address - Street 1:3065 MT. HERMAN RD.
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132
Practice Address - Country:US
Practice Address - Phone:719-322-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0008017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)