MEDICARE: JOHN M O'DONNELL PH.D.

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	103TB0200X	Cognitive & Behavioral Psychologist	561-057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962462093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN M O'DONNELL PH.D.

Provider Business Mailing Address
First Line	:	2121 LOFTY LN
Second Line	:
City	:	SAUKVILLE
State	:	WI
Zip	:	53080-2300
Country	:	US
Telephone Number	:	262-375-8653
Fax Number	:	262-375-0722

Provider Business Practice Location Address
First Line	:	5225 N IRONWOOD LN
Second Line	:	SUITE # 212
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-962-1000
Fax Number	:

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

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	07/09/2007

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Directions to “ JOHN M O'DONNELL PH.D.” Practice Location

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