=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588751853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | O'CONNELL, LONG AND ASSOCIATES COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 01/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 E GENEVA SQ
-----------------------------------------------------
City | LAKE GENEVA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53147-9694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-278-6146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 634
-----------------------------------------------------
City | EAST TROY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53120-0634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-278-6146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/TREASURER
-----------------------------------------------------
Name | MS. SUSAN B O'CONNELL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 262-278-6146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------