Provider Demographics
NPI:1659177798
Name:O'CONNELL, NICHOLAS (CMT, LMT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 1/2 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2023
Mailing Address - Country:US
Mailing Address - Phone:218-390-6579
Mailing Address - Fax:
Practice Address - Street 1:2121 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3610
Practice Address - Country:US
Practice Address - Phone:715-398-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17769-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist