Basic Information
| Provider Information | |||||||||
| NPI: | 1619089232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 WELLS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9046191080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1865 LIME ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043218400 | ||||||||
| FaxNumber: | 9043218401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH 11449 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 252502000 | 05 | MD | MEDICAID | 64228401 | 01 | MD | CAREFIRST NONTAX ID | OTHER |