Basic Information
Provider Information
NPI: 1003000795
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: O'NEILL
FirstName: MICHAEL
MiddleName: JOSEPH
NamePrefix: MR.
NameSuffix:  
Credential: LICSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1919 UNIVERSITY AVE W
Address2:  
City: SAINT PAUL
State: MN
PostalCode: 551043453
CountryCode: US
TelephoneNumber: 6512667900
FaxNumber: 6512667850
Practice Location
Address1: 1919 UNIVERSITY AVE W
Address2:  
City: SAINT PAUL
State: MN
PostalCode: 551043453
CountryCode: US
TelephoneNumber: 6512667900
FaxNumber: 6512667850
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 09/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X17024MNY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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