Provider Demographics
NPI:1477389187
Name:ODONNELL, HEATHER NICOLE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:ODONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 SW HALLMARK ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6524
Mailing Address - Country:US
Mailing Address - Phone:561-294-3128
Mailing Address - Fax:
Practice Address - Street 1:10272 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5615
Practice Address - Country:US
Practice Address - Phone:772-872-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-363772106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician