Provider Demographics
NPI:1447220504
Name:ODONNELL, GEORGE FREDERICK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:FREDERICK
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 CALUSA LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-5348
Mailing Address - Country:US
Mailing Address - Phone:941-483-4869
Mailing Address - Fax:941-483-4869
Practice Address - Street 1:2199 CALUSA LAKES BLVD
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-5348
Practice Address - Country:US
Practice Address - Phone:941-483-4869
Practice Address - Fax:941-483-4869
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011246103T00000X
FLPY8447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVS0331Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER