Healthcare Provider Details

I. General information

NPI: 1972040061
Provider Name (Legal Business Name): TIMOTHY O'CONNELL CATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BIRMINGHAM DR STE 240A
CARDIFF CA
92007-1757
US

IV. Provider business mailing address

10281 KIDD ST
RIVERSIDE CA
92503-3469
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-0121
  • Fax:
Mailing address:
  • Phone: 951-715-5050
  • Fax: 800-498-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19609
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2114485
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: