Provider Demographics
NPI:1699891408
Name:ODONNELL, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:N TOPSAIL BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28460-0458
Mailing Address - Country:US
Mailing Address - Phone:910-328-3334
Mailing Address - Fax:
Practice Address - Street 1:3612 ISLAND DR
Practice Address - Street 2:
Practice Address - City:N TOPSAIL BEACH
Practice Address - State:NC
Practice Address - Zip Code:28460-8204
Practice Address - Country:US
Practice Address - Phone:910-328-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04337OtherBCBS
NC04337OtherNC STATE HEALTH PLAN
NC04337OtherBCBS