MEDICARE: MS. MARY KIMBERLY O'CONNOR LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R048401-1	NY

General Provider Information

NPI Number	:	1336487438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KIMBERLY O'CONNOR LCSW-R

Provider Business Mailing Address
First Line	:	15 SONN DR
Second Line	:
City	:	RYE
State	:	NY
Zip	:	10580-2531
Country	:	US
Telephone Number	:	917-453-2328
Fax Number	:	914-925-9839

Provider Business Practice Location Address
First Line	:	14 ELM PL STE 200
Second Line	:
City	:	RYE
State	:	NY
Zip	:	10580-2951
Country	:	US
Telephone Number	:	917-453-2328
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2013
Last Update Date	:	05/17/2019

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