Provider Demographics
NPI:1629121769
Name:O'CONNELL, SUSAN K (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-2422
Mailing Address - Country:US
Mailing Address - Phone:781-894-8344
Mailing Address - Fax:617-527-2593
Practice Address - Street 1:740 MAIN ST
Practice Address - Street 2:SUITE 115
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-0607
Practice Address - Country:US
Practice Address - Phone:781-894-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1025911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0101949000OtherAETNA
MA1857835Medicaid
MA0101949000OtherAETNA
MA1857835Medicaid