Provider Demographics
NPI:1700902681
Name:O'CONNELL, MOIRA JOSEPHINE (PTA)
Entity Type:Individual
Prefix:MS
First Name:MOIRA
Middle Name:JOSEPHINE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 EDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9050 W.81ST STREET
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:IL
Practice Address - Zip Code:60458
Practice Address - Country:US
Practice Address - Phone:708-496-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant