Provider Demographics
NPI:1841316718
Name:O'DONNELL, JUSTINA MARIE
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:MARIE
Last Name:O'DONNELL
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 1:1620 EAGLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-2902
Mailing Address - Country:US
Mailing Address - Phone:401-624-7324
Mailing Address - Fax:
Practice Address - Street 1:1620 OLD EAGLEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878
Practice Address - Country:US
Practice Address - Phone:401-624-7324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00098224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant