Provider Demographics
NPI:1043547763
Name:O'DONNELL, KIM MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2808
Mailing Address - Country:US
Mailing Address - Phone:203-668-2223
Mailing Address - Fax:
Practice Address - Street 1:142 ELM ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2808
Practice Address - Country:US
Practice Address - Phone:203-668-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002084103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent