Provider Demographics
NPI:1518721075
Name:O'CONNELL, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1823
Mailing Address - Country:US
Mailing Address - Phone:509-699-1494
Mailing Address - Fax:
Practice Address - Street 1:522 W RIVERSIDE AVE STE 4691
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0580
Practice Address - Country:US
Practice Address - Phone:360-605-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61001207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician