Provider Demographics
NPI:1215609763
Name:O'CONNELL, KATHRYN E (LCSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:O'CONNELL
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT STREET
Mailing Address - Street 2:SPACE BASE DELTA 1
Mailing Address - City:PETERSON SPACE FORCE BASE
Mailing Address - State:CO
Mailing Address - Zip Code:80914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21ST MEDICAL GROUP
Practice Address - Street 2:
Practice Address - City:PETERSON SPACE FORCE BASE
Practice Address - State:CO
Practice Address - Zip Code:80914
Practice Address - Country:US
Practice Address - Phone:719-556-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
HILCSW-48161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty