Healthcare Provider Details

I. General information

NPI: 1942862123
Provider Name (Legal Business Name): BRENDAN ODONNEL LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 OAK HOLLOW DR STE B
TRAVERSE CITY MI
49686-5924
US

IV. Provider business mailing address

1458 W TRUMBULL RD
MAPLE CITY MI
49664-9642
US

V. Phone/Fax

Practice location:
  • Phone: 231-714-0282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801112466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: