Provider Demographics
NPI:1780307819
Name:O'CONNELL, AMANDA J
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
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:W62N248 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2768
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:
Practice Address - Street 1:W62N248 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIO2540109351106OtherDRIVERS LICENSE