MEDICARE: KENDRA S O'CONNOR MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34005068A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000663845	OTHER	IN	ANTHEM BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1659330439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRA S O'CONNOR MSW, LCSW

Provider Business Mailing Address
First Line	:	4214 HOBSON CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8648
Country	:	US
Telephone Number	:	260-486-5251
Fax Number	:	260-486-5058

Provider Business Practice Location Address
First Line	:	4214 HOBSON CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8648
Country	:	US
Telephone Number	:	260-486-5251
Fax Number	:	260-486-5058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	08/23/2010

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