Provider Demographics
NPI:1124288410
Name:O'DONNELL, TARA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:MARIE
Last Name:O'DONNELL
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EAST END BOULEVARD
Mailing Address - Street 2:WILKES-BARRE VA MEDICAL CENTER
Mailing Address - City:WILKES-BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711
Mailing Address - Country:US
Mailing Address - Phone:570-824-3521
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical