Healthcare Provider Details

I. General information

NPI: 1114315348
Provider Name (Legal Business Name): BONNIE O'DONNELL CADC II-CA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 THIRTEENTH AVE
LUCERNE CA
95458
US

IV. Provider business mailing address

PO BOX 1024
LUCERNE CA
95458
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9101
  • Fax: 72-749-1927
Mailing address:
  • Phone: 707-274-9101
  • Fax: 707-274-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII053140318
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: