Provider Demographics
NPI:1356823124
Name:O'CONNELL, AIMEE LORRAINE
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:LORRAINE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BELLE TERRE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2318
Mailing Address - Country:US
Mailing Address - Phone:631-689-0220
Mailing Address - Fax:631-686-7626
Practice Address - Street 1:625 BELLE TERRE RD STE 202
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2318
Practice Address - Country:US
Practice Address - Phone:631-689-0220
Practice Address - Fax:631-686-7626
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070537-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker