Provider Demographics
NPI:1588645162
Name:O'DONNELL, MARY JOEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JOEY
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JOEY
Other - Middle Name:
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:50 E 91ST ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1555
Mailing Address - Country:US
Mailing Address - Phone:317-408-9560
Mailing Address - Fax:866-855-8502
Practice Address - Street 1:50 E 91ST ST
Practice Address - Street 2:SUITE 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1549
Practice Address - Country:US
Practice Address - Phone:317-408-9560
Practice Address - Fax:866-855-8502
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041754A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200415660AMedicaid