Provider Demographics
NPI:1023334794
Name:O'CONNELL, MARY ANNE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MARY ANNE
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4024
Mailing Address - Country:US
Mailing Address - Phone:734-662-1959
Mailing Address - Fax:734-662-1959
Practice Address - Street 1:2901 EASRT GRAND RIVER AVE
Practice Address - Street 2:C/O PAM
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843
Practice Address - Country:US
Practice Address - Phone:517-548-1537
Practice Address - Fax:517-548-9399
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085778101YM0800X, 101YP2500X, 1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801085778OtherMI STATE SOCIAL WORK LISCENSE
MISWL001523563OtherPROFESSIONAL LIABILITY INSURANCE