Healthcare Provider Details

I. General information

NPI: 1235525825
Provider Name (Legal Business Name): CYNTHIA CONNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 01/29/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 WYOMING BLVD NE
ALBUQUERQUE NM
87112-2617
US

IV. Provider business mailing address

6400 SOUTHCENTER BLVD
TUKWILA WA
98188-2547
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-1617
  • Fax:
Mailing address:
  • Phone: 206-901-2000
  • Fax: 206-901-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60247080
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: