Provider Demographics
NPI:1447943832
Name:O'CONNOR, KEVIN ROBERT (MS, LPC, MFT-IT, NCC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MS, LPC, MFT-IT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 FOREST GROVE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3765
Mailing Address - Country:US
Mailing Address - Phone:262-470-9131
Mailing Address - Fax:262-691-2972
Practice Address - Street 1:353 FOREST GROVE DR STE 100
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3765
Practice Address - Country:US
Practice Address - Phone:262-470-9131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11090-225101YP2500X
WI11090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty