Healthcare Provider Details

I. General information

NPI: 1962915686
Provider Name (Legal Business Name): SYRIAN M MCCONNICO MA, RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WESTHALL LN STE 207
MAITLAND FL
32751-7478
US

IV. Provider business mailing address

769 PINE ISLAND DR
MELBOURNE FL
32940-1709
US

V. Phone/Fax

Practice location:
  • Phone: 407-636-3532
  • Fax:
Mailing address:
  • Phone: 321-271-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: