Provider Demographics
NPI:1992189526
Name:O'CONNELL, TIMOTHY PATRICK (IMH11386)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:IMH11386
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E PACKWOOD AVE
Mailing Address - Street 2:APT D106
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5700
Mailing Address - Country:US
Mailing Address - Phone:407-620-7287
Mailing Address - Fax:
Practice Address - Street 1:430 E PACKWOOD AVE
Practice Address - Street 2:APT D106
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5700
Practice Address - Country:US
Practice Address - Phone:407-620-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH11386101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health