Provider Demographics
NPI:1720194392
Name:O'DELL, DOUGLAS K (MA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:O'DELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-4607
Mailing Address - Country:US
Mailing Address - Phone:503-657-7232
Mailing Address - Fax:
Practice Address - Street 1:10163 SE SUNNYSIDE RD STE 490
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5720
Practice Address - Country:US
Practice Address - Phone:503-513-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 97-04-47101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)