Basic Information
| Provider Information | |||||||||
| NPI: | 1164845269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 UNSER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058960928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 184 UNSER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871244045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058960928 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 05/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 0165461 | NM | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 0184251 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.