Healthcare Provider Details

I. General information

NPI: 1922584788
Provider Name (Legal Business Name): MARCIA RUTH O'DONNELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E VERNON AVE STE 104
NORMAL IL
61761-3813
US

IV. Provider business mailing address

34 PAYNE PL
NORMAL IL
61761-3576
US

V. Phone/Fax

Practice location:
  • Phone: 309-287-7539
  • Fax:
Mailing address:
  • Phone: 309-287-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.009081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: