Healthcare Provider Details

I. General information

NPI: 1407452121
Provider Name (Legal Business Name): CAITLYN O'CONNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SE DELAWARE AVE STE O
ANKENY IA
50021-4011
US

IV. Provider business mailing address

1555 SE DELAWARE AVE STE O
ANKENY IA
50021-4011
US

V. Phone/Fax

Practice location:
  • Phone: 515-261-2402
  • Fax:
Mailing address:
  • Phone: 515-261-2402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1407452121
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: