Provider Demographics
NPI:1053551473
Name:O'DONNELL, VIRGINIA A (BSW)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 OMAR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2960
Mailing Address - Country:US
Mailing Address - Phone:586-469-6674
Mailing Address - Fax:
Practice Address - Street 1:21885 DUNHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1030
Practice Address - Country:US
Practice Address - Phone:586-469-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities