Provider Demographics
NPI:1619089232
Name:O'DONNELL, MARY (LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:1865 LIME ST STE 100
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4779
Practice Address - Country:US
Practice Address - Phone:904-321-8400
Practice Address - Fax:904-321-8401
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 11449101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD252502000Medicaid
MD64228401OtherCAREFIRST NONTAX ID