Healthcare Provider Details

I. General information

NPI: 1952749277
Provider Name (Legal Business Name): SYDNI O'CONNELL LEP, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2013
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date: 11/11/2021
Reactivation Date: 12/01/2021

III. Provider practice location address

745 HIGH ST STE 204
WESTWOOD MA
02090-2535
US

IV. Provider business mailing address

200 REVERE ST APT 108
CANTON MA
02021-3064
US

V. Phone/Fax

Practice location:
  • Phone: 508-404-8796
  • Fax:
Mailing address:
  • Phone: 508-404-8796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1221-MH-ED
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: