Provider Demographics
NPI:1912992819
Name:O'DANOVICH, MARTHA M (PSYD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:O'DANOVICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 BROADWAY
Mailing Address - Street 2:F1
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8602
Mailing Address - Country:US
Mailing Address - Phone:219-736-1000
Mailing Address - Fax:219-736-9699
Practice Address - Street 1:8300 BROADWAY
Practice Address - Street 2:F1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-736-1000
Practice Address - Fax:219-736-9699
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000126A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200136790Medicaid
IN408460MMedicare PIN
IN200136790Medicaid