Provider Demographics
NPI:1174765697
Name:O'DELL, SHAWNESSY PATRICK (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHAWNESSY
Middle Name:PATRICK
Last Name:O'DELL
Suffix:
Gender:M
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:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95071-0392
Mailing Address - Country:US
Mailing Address - Phone:408-603-1496
Mailing Address - Fax:
Practice Address - Street 1:20688 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-5894
Practice Address - Country:US
Practice Address - Phone:408-603-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY23275103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist