Healthcare Provider Details

I. General information

NPI: 1053127126
Provider Name (Legal Business Name): CONNOR ROBERT HENRY LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 DERBT STREET SUITE 21
HINGHAM MA
02043
US

IV. Provider business mailing address

1258 MASSACHUSETTS AVE APT 508
BOSTON MA
02125-4803
US

V. Phone/Fax

Practice location:
  • Phone: 781-424-8119
  • Fax:
Mailing address:
  • Phone: 860-818-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1120143
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: