Provider Demographics
NPI:1487923611
Name:O'CONNOR, CHARLES (LPC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 UNION WALK CIR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3657
Mailing Address - Country:US
Mailing Address - Phone:678-524-5609
Mailing Address - Fax:
Practice Address - Street 1:3091 E SHADOWLAWN AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2481
Practice Address - Country:US
Practice Address - Phone:678-524-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006312101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health