MEDICARE: DR. NEIL FREDERICK O'DONNELL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301011534	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	68-0-B8-4532-0	OTHER	MI	BLUE CROSS
2	11284895	OTHER	MI	CAQH

General Provider Information

NPI Number	:	1548300601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEIL FREDERICK O'DONNELL PH.D.

Provider Business Mailing Address
First Line	:	2150 S AIRPORT RD W
Second Line	:	SUITE A
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4705
Country	:	US
Telephone Number	:	231-929-4399
Fax Number	:	231-929-4790

Provider Business Practice Location Address
First Line	:	2150 S AIRPORT RD W
Second Line	:	SUITE A
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4705
Country	:	US
Telephone Number	:	231-929-4399
Fax Number	:	231-929-4790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	01/28/2011

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Directions to “ DR. NEIL FREDERICK O'DONNELL PH.D.” Practice Location

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