Provider Demographics
NPI:1578667168
Name:ODONNELL, JOHN J (D MIN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:D MIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 RTE 101A
Mailing Address - Street 2:#10
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031
Mailing Address - Country:US
Mailing Address - Phone:603-673-7699
Mailing Address - Fax:
Practice Address - Street 1:89 RTE 101A
Practice Address - Street 2:#10
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031
Practice Address - Country:US
Practice Address - Phone:603-673-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99001812Medicaid