Healthcare Provider Details

I. General information

NPI: 1285729715
Provider Name (Legal Business Name): SETH O'CONNOR LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MARION AVE
WATERFORD MI
48328-3232
US

IV. Provider business mailing address

480 MARION AVE
WATERFORD MI
48328-3232
US

V. Phone/Fax

Practice location:
  • Phone: 248-635-3196
  • Fax:
Mailing address:
  • Phone: 248-635-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801079258
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: