Provider Demographics
NPI:1881679173
Name:O NEILL, KATHLEEN M (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:O NEILL
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3334
Mailing Address - Country:US
Mailing Address - Phone:920-262-4800
Mailing Address - Fax:920-262-4813
Practice Address - Street 1:129 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3334
Practice Address - Country:US
Practice Address - Phone:920-262-4800
Practice Address - Fax:920-262-4813
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66841231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39794300Medicaid
WI0840310006Medicare ID - Type Unspecified