Provider Demographics
NPI:1922584788
Name:O'DONNELL, MARCIA RUTH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:RUTH
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PAYNE PL
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3576
Mailing Address - Country:US
Mailing Address - Phone:309-287-7539
Mailing Address - Fax:
Practice Address - Street 1:407 E VERNON AVE STE 104
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3813
Practice Address - Country:US
Practice Address - Phone:309-287-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0090811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical