Provider Demographics
NPI:1962462093
Name:O'DONNELL, JOHN M (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 LOFTY LN
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2300
Mailing Address - Country:US
Mailing Address - Phone:262-375-8653
Mailing Address - Fax:262-375-0722
Practice Address - Street 1:5225 N IRONWOOD LN
Practice Address - Street 2:SUITE # 212
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4909
Practice Address - Country:US
Practice Address - Phone:414-962-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI561-057103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39055600Medicaid
WI39055600Medicaid