Healthcare Provider Details

I. General information

NPI: 1588751853
Provider Name (Legal Business Name): O'CONNELL, LONG AND ASSOCIATES COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E GENEVA SQ
LAKE GENEVA WI
53147-9694
US

IV. Provider business mailing address

PO BOX 634
EAST TROY WI
53120-0634
US

V. Phone/Fax

Practice location:
  • Phone: 262-278-6146
  • Fax:
Mailing address:
  • Phone: 262-278-6146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. SUSAN B O'CONNELL
Title or Position: SECRETARY/TREASURER
Credential: LCSW
Phone: 262-278-6146