MEDICARE: BRIAN MACCONNELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1588135727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN MACCONNELL

Provider Business Mailing Address
First Line	:	4531 READING RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-1229
Country	:	US
Telephone Number	:	513-706-0140
Fax Number	:

Provider Business Practice Location Address
First Line	:	4531 READING RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-1229
Country	:	US
Telephone Number	:	513-706-0140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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