MEDICARE: CATHY SUPON CONNOR LLC

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	SW8892	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669897443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHY SUPON CONNOR LLC

Provider Business Mailing Address
First Line	:	429 S TYNDALL PKWY STE G
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-6746
Country	:	US
Telephone Number	:	850-381-3701
Fax Number	:

Provider Business Practice Location Address
First Line	:	429 S TYNDALL PKWY STE G
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-6746
Country	:	US
Telephone Number	:	850-381-3701
Fax Number	:

Authorized Official
Title or Position	:	LCSW/OWNER
Name	:	MRS. CATHY SUPON CONNOR
Credential	:	LCSW
Telephone Number	:	850-381-1520

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	05/23/2014

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