Provider Demographics
NPI:1740839695
Name:MCDANIEL O'CONNELL, LAURA ANN (SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:MCDANIEL O'CONNELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 E CORONADO AVE SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-0900
Mailing Address - Country:US
Mailing Address - Phone:336-404-4802
Mailing Address - Fax:
Practice Address - Street 1:4330 SOUTHPORT SUPPLY RD SE STE 201
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9273
Practice Address - Country:US
Practice Address - Phone:910-612-1002
Practice Address - Fax:910-755-5865
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14966235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14966OtherNC BOARD OF SLPS
VA2204000398OtherLICENSE NUMBER