Provider Demographics
NPI:1871211318
Name:OCONNOR, SHAUN MICHAEL
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:OCONNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:MI
Mailing Address - Zip Code:49733-0230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5524 CHICKASAW TRL
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:MI
Practice Address - Zip Code:49733-9517
Practice Address - Country:US
Practice Address - Phone:989-889-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician