Provider Demographics
NPI:1154086676
Name:O'DONNELL, BRENDAN
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CENTERVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4376
Mailing Address - Country:US
Mailing Address - Phone:401-737-6011
Mailing Address - Fax:
Practice Address - Street 1:982 TIOGUE AVE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-6116
Practice Address - Country:US
Practice Address - Phone:401-615-3140
Practice Address - Fax:401-615-8611
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT03258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist