=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285975417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETH O'DONNELL, PH.D. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2013
-----------------------------------------------------
Last Update Date | 08/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 W MAIN ST SUITE 106G
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-992-8943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 W MAIN ST SUITE 106G
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-992-8943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DR. ELIZABETH DANEKER O'DONNELL
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 917-992-8943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 003189
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------