Provider Demographics
NPI:1609114933
Name:O'DONNELL, ELIZABETH DANEKER (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:DANEKER
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 LOCKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-1920
Mailing Address - Country:US
Mailing Address - Phone:203-637-0537
Mailing Address - Fax:
Practice Address - Street 1:153 LOCKWOOD RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878-1920
Practice Address - Country:US
Practice Address - Phone:203-637-0537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012861103TC0700X
CT003189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV91971OtherMEDICARE PROVIDER #
NY01792772Medicaid