Provider Demographics
NPI:1518197110
Name:O'CONNELL, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:HALLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8048
Mailing Address - Country:US
Mailing Address - Phone:631-603-2047
Mailing Address - Fax:
Practice Address - Street 1:215 ROSE ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8048
Practice Address - Country:US
Practice Address - Phone:631-603-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCB0006761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical