Provider Demographics
NPI:1619096237
Name:O'CONNELL, MICHAEL J (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 W GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-5624
Mailing Address - Country:US
Mailing Address - Phone:865-522-6060
Mailing Address - Fax:865-522-9218
Practice Address - Street 1:518 W GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5624
Practice Address - Country:US
Practice Address - Phone:865-522-6060
Practice Address - Fax:865-522-9218
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2006400OtherBLUE CROSS BLUE SHIELD