Provider Demographics
NPI:1831617356
Name:OCONNELL, ELYSE M
Entity type:Individual
Prefix:MRS
First Name:ELYSE
Middle Name:M
Last Name:OCONNELL
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 1:1616 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-3641
Mailing Address - Country:US
Mailing Address - Phone:850-319-1525
Mailing Address - Fax:
Practice Address - Street 1:892 27TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1444
Practice Address - Country:US
Practice Address - Phone:619-575-4687
Practice Address - Fax:619-575-1215
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty