Provider Demographics
NPI:1275571077
Name:O'DONNELL, EUGENE (LCSW)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MONTAGE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1782
Mailing Address - Country:US
Mailing Address - Phone:570-346-3686
Mailing Address - Fax:570-558-6838
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:570-558-6838
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0129031041C0700X
PAMA-003535-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA292096Q9ZOtherMEDICARE
PA696250Medicare PIN
PAS23082Medicare UPIN
PA102313034Medicaid