Provider Demographics
NPI:1730638834
Name:O'NEIL, ELLEN (TESS)
Entity type:Individual
Prefix:MISS
First Name:ELLEN (TESS)
Middle Name:
Last Name:O'NEIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 UNIVERSITY AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3264
Mailing Address - Country:US
Mailing Address - Phone:510-841-1262
Mailing Address - Fax:
Practice Address - Street 1:1918 UNIVERSITY AVE STE 2B
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:510-841-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE171410390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program