MEDICARE: MR. CHRISTOPHER J O'DONNELL LCSW

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	1041C0700X	Clinical Social Worker	082292	NY

General Provider Information

NPI Number	:	1134416027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHRISTOPHER J O'DONNELL LCSW

Provider Business Mailing Address
First Line	:	11 ROUTE 111
Second Line	:
City	:	SMITHTOWN
State	:	NY
Zip	:	11787-3712
Country	:	US
Telephone Number	:	631-265-4622
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 MIDDLEVILLE RD
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2296
Country	:	US
Telephone Number	:	631-682-7152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	06/28/2022

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