Provider Demographics
NPI:1760521314
Name:O'DONNELL, ANN CLARE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:CLARE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 S AIRPORT RD W
Mailing Address - Street 2:SUITE A
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:SUITE A
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011799103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-B8-1130-0OtherBLUE CROSS
MI467872OtherVALUE OPTIONS
MI11413109OtherCAQH