Healthcare Provider Details

I. General information

NPI: 1558028852
Provider Name (Legal Business Name): CARRIE O'CONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2021
Last Update Date: 01/05/2022
Certification Date: 12/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

IV. Provider business mailing address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6571
  • Fax:
Mailing address:
  • Phone: 319-235-6571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG166325
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: