Healthcare Provider Details

I. General information

NPI: 1073940102
Provider Name (Legal Business Name): LISA O'CONNELL M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 N LAKE DR 7TH FLOOR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

2323 N. LAKE DRIVE 7TH FLOOR
MILWAUKEE WI
53208
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1000
  • Fax:
Mailing address:
  • Phone: 414-291-1248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3721154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: