Provider Demographics
NPI:1245554971
Name:O'CONNELL, KEVIN M (OTR)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:50 GOLD STAR BLVD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2812
Mailing Address - Country:US
Mailing Address - Phone:508-856-9510
Mailing Address - Fax:
Practice Address - Street 1:635 BELLE TERRE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1935
Practice Address - Country:US
Practice Address - Phone:631-331-3608
Practice Address - Fax:631-331-2392
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016051-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist