Provider Demographics
NPI:1225111537
Name:SMITH-O'CONNOR, DIANNE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:MARIE
Last Name:SMITH-O'CONNOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 PO ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-2520
Mailing Address - Country:US
Mailing Address - Phone:262-334-7227
Mailing Address - Fax:
Practice Address - Street 1:279 S 17TH AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3001
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-306-9317
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1705-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health