MEDICARE: WILLIAM O DONNELLY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2758	OH

General Provider Information

NPI Number	:	1437146867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM O DONNELLY PH.D.

Provider Business Mailing Address
First Line	:	DONNELLY COMMUNITY PSYCHOLOGY
Second Line	:	429 W. COLLEGE AVENUE, PO BOX 105
City	:	PEMBERVILLE
State	:	OH
Zip	:	43450-0105
Country	:	US
Telephone Number	:	419-972-1211
Fax Number	:

Provider Business Practice Location Address
First Line	:	429 W. COLLEGE AVE
Second Line	:	DONNELLY COMMUNITY PSYCHOLOGY
City	:	PEMBERVILLE
State	:	OH
Zip	:	43450
Country	:	US
Telephone Number	:	419-972-1211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/19/2011

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