Provider Demographics
NPI:1750781233
Name:O'DONNELL, ROBERT JOSEPH (CASAC-T)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-0207
Mailing Address - Country:US
Mailing Address - Phone:917-533-9350
Mailing Address - Fax:
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3753
Practice Address - Country:US
Practice Address - Phone:631-920-8306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program