Provider Demographics
NPI:1902810468
Name:O'DONNELL, IDA M (LCSW)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:M
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 1:813 BROADWAY
Mailing Address - Street 2:ART OF AWARENESS, INC.
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2708
Mailing Address - Country:US
Mailing Address - Phone:207-799-1331
Mailing Address - Fax:207-799-1350
Practice Address - Street 1:813 BROADWAY
Practice Address - Street 2:ART OF AWARENESS, INC.
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2708
Practice Address - Country:US
Practice Address - Phone:207-799-1331
Practice Address - Fax:207-799-1350
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC46761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical