Provider Demographics
NPI:1720384415
Name:NEIL F. O'DONNELL, PHD, P.C.
Entity Type:Organization
Organization Name:NEIL F. O'DONNELL, PHD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:CLARE
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:231-929-9511
Mailing Address - Street 1:2150 S AIRPORT RD W
Mailing Address - Street 2:SUITEA
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4705
Mailing Address - Country:US
Mailing Address - Phone:231-929-9511
Mailing Address - Fax:231-929-4790
Practice Address - Street 1:2150 S AIRPORT RD W
Practice Address - Street 2:SUITEA
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4705
Practice Address - Country:US
Practice Address - Phone:231-929-9511
Practice Address - Fax:231-929-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011534103TC0700X
MI6301011799103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-B8-4532-0OtherBLUE CROSS BLUE SHEILD MICHIGAN
MI68-0-B8-1130-0OtherBLUE CROSS BLUE SHEILD MICHIGAN
MIP30451Medicare UPIN
MI68-0-B8-4532-0OtherBLUE CROSS BLUE SHEILD MICHIGAN