Provider Demographics
NPI:1851999080
Name:ODANIEL, LINDA D (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:D
Last Name:ODANIEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12904 DIVISION ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3420
Mailing Address - Country:US
Mailing Address - Phone:773-236-6511
Mailing Address - Fax:
Practice Address - Street 1:12904 DIVISION ST APT 2A
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-3420
Practice Address - Country:US
Practice Address - Phone:773-236-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 133NN1002X, 172V00000X, 174H00000X, 251B00000X
IL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No251B00000XAgenciesCase Management