MEDICARE: NEIL F. O'DONNELL, PHD, P.C.

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	6301011799	MI
2	103TC2200X	Clinical Child & Adolescent Psychologist	6301011799	MI
3	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 BLUE SHEILD MICHIGAN
2	68-0-B8-1130-0	OTHER	MI	BLUE CROSS BLUE SHEILD MICHIGAN

General Provider Information

NPI Number	:	1720384415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEIL F. O'DONNELL, PHD, P.C.

Provider Business Mailing Address
First Line	:	2150 S AIRPORT RD W
Second Line	:	SUITEA
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4705
Country	:	US
Telephone Number	:	231-929-9511
Fax Number	:	231-929-4790

Provider Business Practice Location Address
First Line	:	2150 S AIRPORT RD W
Second Line	:	SUITEA
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-4705
Country	:	US
Telephone Number	:	231-929-9511
Fax Number	:	231-929-4790

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. ANN CLARE O'DONNELL
Credential	:	PSYD
Telephone Number	:	231-929-9511

Provider Enumeration Date	:	01/28/2011
Last Update Date	:	01/28/2011

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Directions to “NEIL F. O'DONNELL, PHD, P.C. ” Practice Location

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