MEDICARE: ELIZABETH O'CONNOR

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	235Z00000X	Speech-Language Pathologist	011154	NY

General Provider Information

NPI Number	:	1912139858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH O'CONNOR

Provider Business Mailing Address
First Line	:	1156 71ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-1304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1156 71ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-1304
Country	:	US
Telephone Number	:	718-972-0880
Fax Number	:	718-972-0696

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

Provider Enumeration Date	:	08/11/2009
Last Update Date	:	08/11/2009

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