=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285049908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FELICIA CONNOR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2014
-----------------------------------------------------
Last Update Date | 06/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 BLEVINS DR SUITE 5
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19720-4177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-635-7087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 536
-----------------------------------------------------
City | HOCKESSIN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19707-0536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-635-7087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FELICIA CONNOR
-----------------------------------------------------
Credential | CP
-----------------------------------------------------
Telephone | 302-635-7087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | B1-0000959
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------