Healthcare Provider Details

I. General information

NPI: 1164845269
Provider Name (Legal Business Name): SHAWN DAVID O'CONNELL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

184 UNSER BLVD NE
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 505-896-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0165461
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0184251
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: