Provider Demographics
NPI:1417046376
Name:O'CONNELL, SUSAN B (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:B
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:MSW, LCSW
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 634
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-0634
Mailing Address - Country:US
Mailing Address - Phone:262-278-6146
Mailing Address - Fax:
Practice Address - Street 1:166 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:262-278-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3011-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391657985019OtherANTHEM BLUE CROSS