Basic Information
| Provider Information | |||||||||
| NPI: | 1942350467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'NEILL | ||||||||
| FirstName: | LISE | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 NORTHFIELD ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060422335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606469794 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MANCHESTER MEMORIAL HOSPITAL | ||||||||
| Address2: | 71 HAYNES ST | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605333434 | ||||||||
| FaxNumber: | 8606476829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 000529 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 004025177 | 05 | CT | MEDICAID |