Provider Demographics
NPI:1508407040
Name:O'CONNELL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 INLET DR
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6809
Mailing Address - Country:US
Mailing Address - Phone:631-678-5115
Mailing Address - Fax:
Practice Address - Street 1:173 INLET DR
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-6809
Practice Address - Country:US
Practice Address - Phone:631-678-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No252Y00000XAgenciesEarly Intervention Provider Agency