=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194443770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE OCONNELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 08/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 SHIRLEY AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-6624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-691-8936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7503 BRAEMAR CT
-----------------------------------------------------
City | SYKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-6679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-691-8936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------