Provider Demographics
NPI:1023366689
Name:O'DONNELL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:O'DONNELL
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 1:730 N EASTERN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101
Mailing Address - Country:US
Mailing Address - Phone:702-772-4864
Mailing Address - Fax:866-442-8199
Practice Address - Street 1:730 N EASTERN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101
Practice Address - Country:US
Practice Address - Phone:702-772-4864
Practice Address - Fax:866-442-8199
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor