Provider Demographics
NPI:1568091304
Name:O'DONNELL, TIMOTHY (ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 NEWTON AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLYN
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-1067
Mailing Address - Country:US
Mailing Address - Phone:609-870-0104
Mailing Address - Fax:
Practice Address - Street 1:301 2ND AVE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1407
Practice Address - Country:US
Practice Address - Phone:856-547-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001142002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer