Provider Demographics
NPI:1447595137
Name:O'DONNELL, COLLEEN M (LCAT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BROADWAY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3290
Mailing Address - Country:US
Mailing Address - Phone:516-458-5664
Mailing Address - Fax:
Practice Address - Street 1:211 BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3290
Practice Address - Country:US
Practice Address - Phone:516-458-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05 000491101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor