Provider Demographics
NPI:1679733554
Name:O'DONNELL, KEITH MICHAEL (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:MICHAEL
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 RIDGEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1937
Mailing Address - Country:US
Mailing Address - Phone:203-516-8852
Mailing Address - Fax:
Practice Address - Street 1:500 MONROE TPKE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2354
Practice Address - Country:US
Practice Address - Phone:203-520-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040655Medicaid