Provider Demographics
NPI:1588701791
Name:O'CONNELL, KEVIN JAMES (MA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BAYVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03824-2406
Mailing Address - Country:US
Mailing Address - Phone:603-397-5028
Mailing Address - Fax:603-889-9639
Practice Address - Street 1:16 BAYVIEW RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824-2406
Practice Address - Country:US
Practice Address - Phone:603-397-5028
Practice Address - Fax:603-889-9639
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH457101YA0400X
MA769101YA0400X
MA0918AL101YA0400X
NH341101YM0800X
MA3790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30420903Medicaid