Provider Demographics
NPI:1114208576
Name:O'DONNELL, NATASHA BROOKE (LCP, LMLP)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:BROOKE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LCP, LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-5010
Mailing Address - Country:US
Mailing Address - Phone:316-284-6402
Mailing Address - Fax:316-284-6383
Practice Address - Street 1:1901 E 1ST ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-5010
Practice Address - Country:US
Practice Address - Phone:316-284-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP 1395103TC0700X
KSLMLP2436103TC0700X
KSLCP1450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200737670EMedicaid