Healthcare Provider Details

I. General information

NPI: 1124265939
Provider Name (Legal Business Name): THOMAS R. CONNOR MA LPC WY#579
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 E 3RD ST STE 104
CASPER WY
82601-3200
US

IV. Provider business mailing address

940 E 3RD ST STE 104
CASPER WY
82601-3200
US

V. Phone/Fax

Practice location:
  • Phone: 307-462-4876
  • Fax: 307-337-3492
Mailing address:
  • Phone: 307-462-4876
  • Fax: 307-337-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberWY#579
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-579
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: