Provider Demographics
NPI:1992729610
Name:CONNOR, MARY GINA (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:GINA
Last Name:CONNOR
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 ERLANGER RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-1468
Mailing Address - Country:US
Mailing Address - Phone:859-342-6444
Mailing Address - Fax:859-342-0999
Practice Address - Street 1:495 ERLANGER RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-1468
Practice Address - Country:US
Practice Address - Phone:859-342-6444
Practice Address - Fax:859-342-0999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP65718Medicare UPIN
KYCSW0287Medicare ID - Type Unspecified