Healthcare Provider Details

I. General information

NPI: 1194795369
Provider Name (Legal Business Name): GEORGE W O'NEILL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 13TH AVE E
WEST FARGO ND
58078-3468
US

IV. Provider business mailing address

1401 13TH AVE E
WEST FARGO ND
58078-3468
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-0060
  • Fax: 701-364-0065
Mailing address:
  • Phone: 701-364-0060
  • Fax: 701-364-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number96
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: