Provider Demographics
NPI:1215392162
Name:CORNELL O'DONNELL, KAITLIN E (DPT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:E
Last Name:CORNELL O'DONNELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2557 HOOPER AVE
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6238
Mailing Address - Country:US
Mailing Address - Phone:732-701-3711
Mailing Address - Fax:732-701-3709
Practice Address - Street 1:2557 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6238
Practice Address - Country:US
Practice Address - Phone:732-701-3711
Practice Address - Fax:732-701-3709
Is Sole Proprietor?:No
Enumeration Date:2015-12-19
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01646200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist