Provider Demographics
NPI:1295958023
Name:CONNER, VIRGINIA LEA (EDD)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LEA
Last Name:CONNER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 S MCCORMICK ST STE 109
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4730
Mailing Address - Country:US
Mailing Address - Phone:928-710-8800
Mailing Address - Fax:928-777-8020
Practice Address - Street 1:141 S MCCORMICK ST STE 109
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303
Practice Address - Country:US
Practice Address - Phone:928-710-8800
Practice Address - Fax:928-777-8020
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1004103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860969406OtherFEDERAL ID NUMBER
AZZ128363Medicare PIN