Healthcare Provider Details

I. General information

NPI: 1093934440
Provider Name (Legal Business Name): MICHAEL LEONARD CONNOR PSYD, MSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

165 CENTRAL PARK AVE APT 813
VIRGINIA BEACH VA
23462-3400
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-4838
  • Fax:
Mailing address:
  • Phone: 757-953-4838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003080
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number301888
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: