Provider Demographics
NPI:1366560351
Name:O'DONNELL, EDMOND G (MFT)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:G
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N. SAN ANTONIO AVE.
Mailing Address - Street 2:P. O. BOX 608
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784
Mailing Address - Country:US
Mailing Address - Phone:909-985-2803
Mailing Address - Fax:909-982-8643
Practice Address - Street 1:9631 BUSINESS CENTER DR
Practice Address - Street 2:BUILDING 14, SUITE E
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4545
Practice Address - Country:US
Practice Address - Phone:909-945-8894
Practice Address - Fax:909-945-2855
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7839106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist